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Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
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Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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2
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Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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3
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Computed Tomography Angiography (CTA) in Selected Scenarios with Risk of Possible False-Positive or False-Negative Conclusions in Diagnosing Brain Death. LIFE (BASEL, SWITZERLAND) 2022; 12:life12101551. [PMID: 36294986 PMCID: PMC9604663 DOI: 10.3390/life12101551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
It is widely accepted that brain death (BD) is a diagnosis based on clinical examination. However, false-positive and false-negative evaluation results may be serious limitations. Ancillary tests are used when there is uncertainty about the reliability of the neurologic examination. Computed tomography angiography (CTA) is an ancillary test that tends to have the lowest false-positive rates. However, there are various influencing factors that can have an unfavorable effect on the validity of the examination method. There are inconsistent protocols regarding the evaluation criteria such as scoring systems. Among the most widely used different scoring systems the 4-point CTA-scoring system has been accepted as the most reliable method. Appropriate timing and/or Doppler pre-testing could reduce the number of possible premature examinations and increase the sensitivity of CTA in diagnosing cerebral circulatory arrest (CCA). In some cases of inconclusive CTA, the whole brain computed tomography perfusion (CTP) could be a crucial adjunct. Due to the increasing significance of CTA/CTP in determining BD, the methodology (including benefits and limitations) should also be conveyed via innovative electronic training tools, such as the BRAINDEXweb teaching tool based on an expert system.
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4
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Zamani N, Hassanian-Moghaddam H, Zamani N. Strategies for the treatment of acute benzodiazepine toxicity in a clinical setting: the role of antidotes. Expert Opin Drug Metab Toxicol 2022; 18:367-379. [PMID: 35875992 DOI: 10.1080/17425255.2022.2105692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although not a potentially life-threatening poisoning, benzodiazepine (BZD) intoxication may be life-threatening in special situations/populations or those with background diseases. AREAS COVERED The aim of this review is to evaluate all possible treatment options available in the literature for the management of benzodiazepine poisoning with special attention to antidote administration. We conducted a literature search using PubMed, Google Scholar, EMBASE, and Cochrane central register from 1 January 1980 to 10 November 2021 using keywords 'benzodiazepine,' 'poisoning,' 'toxicity,' 'intoxication,' and 'treatment.' EXPERT OPINION Careful patient selection, ideally by a clinical toxicologist, may decrease the complications of flumazenil and add to its efficacy. The cost-to-benefit ratio should be considered in every single patient who is a candidate for flumazenil administration. In case a decision has been made to administer flumazenil, careful consideration of the possible contraindications is essential. We recommend slow administration of low doses of flumazenil (0.1 mg/minute) to avoid complications or withhold the administration with development of first signs of adverse effects. The main treatment of benzodiazepine toxicity is conservative with administration of activated charcoal, monitoring of the vital signs, prevention of aspiration and development of deep vein thrombosis due to prolonged immobilization, and respiratory support.
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Affiliation(s)
- Nasim Zamani
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naghmeh Zamani
- Department of Biology, Tehran North Branch, Islamic Azad University, Tehran, Iran
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5
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Mundy PC, Pressly B, Carty DR, Yaghoobi B, Wulff H, Lein PJ. The efficacy of γ-aminobutyric acid type A receptor (GABA AR) subtype-selective positive allosteric modulators in blocking tetramethylenedisulfotetramine (TETS)-induced seizure-like behavior in larval zebrafish with minimal sedation. Toxicol Appl Pharmacol 2021; 426:115643. [PMID: 34265354 PMCID: PMC8514104 DOI: 10.1016/j.taap.2021.115643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/02/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022]
Abstract
The chemical threat agent tetramethylenedisulfotetramine (TETS) is a γ-aminobutyric acid type A receptor (GABA AR) antagonist that causes life threatening seizures. Currently, there is no specific antidote for TETS intoxication. TETS-induced seizures are typically treated with benzodiazepines, which function as nonselective positive allosteric modulators (PAMs) of synaptic GABAARs. The major target of TETS was recently identified as the GABAAR α2β3γ2 subtype in electrophysiological studies using recombinantly expressed receptor combinations. Here, we tested whether these in vitro findings translate in vivo by comparing the efficacy of GABAAR subunit-selective PAMs in reducing TETS-induced seizure behavior in larval zebrafish. We tested PAMs targeting α1, α2, α2/3/5, α6, ß2/3, ß1/2/3, and δ subunits and compared their efficacy to the benzodiazepine midazolam (MDZ). The data demonstrate that α2- and α6-selective PAMs (SL-651,498 and SB-205384, respectively) were effective at mitigating TETS-induced seizure-like behavior. Combinations of SB-205384 and MDZ or SL-651,498 and 2–261 (ß2/3-selective) mitigated TETS-induced seizure-like behavior at concentrations that did not elicit sedating effects in a photomotor behavioral assay, whereas MDZ alone caused sedation at the concentration required to stop seizure behavior. Isobologram analyses suggested that SB-205384 and MDZ interacted in an antagonistic fashion, while the effects of SL-651,498 and 2–261 were additive. These results further elucidate the molecular mechanism by which TETS induces seizures and provide mechanistic insight regarding specific countermeasures against this chemical convulsant.
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Affiliation(s)
- Paige C Mundy
- Department of Molecular Biosciences, University of California, School of Veterinary Medicine, Davis, CA 95616, United States.
| | - Brandon Pressly
- Department of Pharmacology, University of California, School of Medicine, Davis, CA 95616, United States.
| | - Dennis R Carty
- Department of Molecular Biosciences, University of California, School of Veterinary Medicine, Davis, CA 95616, United States
| | - Bianca Yaghoobi
- Department of Molecular Biosciences, University of California, School of Veterinary Medicine, Davis, CA 95616, United States.
| | - Heike Wulff
- Department of Pharmacology, University of California, School of Medicine, Davis, CA 95616, United States.
| | - Pamela J Lein
- Department of Molecular Biosciences, University of California, School of Veterinary Medicine, Davis, CA 95616, United States.
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6
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Schult RF, Omar D, Wiegand TJ, Gordetsky RM, Acquisto NM. Experience with lower dose flumazenil at an academic medical center. Am J Emerg Med 2021; 49:399-401. [PMID: 33581937 DOI: 10.1016/j.ajem.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
- Rachel F Schult
- Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Avenue, Box 638, Rochester, NY 14642, USA; Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Deena Omar
- Department of Pharmacy, Hartford Hospital, Hartford, CT, USA.
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Rachel M Gordetsky
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA; D'Youville College School of Pharmacy, Buffalo, NY, USA.
| | - Nicole M Acquisto
- Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Avenue, Box 638, Rochester, NY 14642, USA; Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA.
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7
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Ebrahimi S, Hassanian-Moghaddam H. Re: Antagonizing the errors of history: bedside experience with flumazenil. TOXICOLOGY COMMUNICATIONS 2021. [DOI: 10.1080/24734306.2020.1871550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Sara Ebrahimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Clinical Toxicology, Loghman Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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8
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Shukla L, Ghadigaonkar DS, Murthy P. Poisoning with Drugs of Abuse: Identification and Management. Indian J Crit Care Med 2020; 23:S296-S304. [PMID: 32021008 PMCID: PMC6996663 DOI: 10.5005/jp-journals-10071-23309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Substances of abuse include alcohol, nicotine, cannabinoids, opioids, sedatives, volatile solvents, stimulants, and hallucinogens. With the increasing prevalence of drug abuse in India, intensivists are likely to encounter more cases of intentional and accidental poisoning due to drugs of abuse. We aim to sensitize the intensivists to challenges involved in diagnosing and treating poisoning with drugs of abuse. We also aim to provide a hands-on primer that can augment the usual protocols of “approach to life-threatening poisoning”. A toxidrome approach along with urine drug testing can help in speedily arriving at a diagnosis and instituting definitive treatment. In this article, we discuss spurious alcohol poisoning (methanol poisoning), benzodiazepine, opioid, and stimulant poisoning in detail and poisoning due to other substances including newer psychoactive substances is discussed briefly.
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Affiliation(s)
- Lekhansh Shukla
- Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Deepak S Ghadigaonkar
- Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Pratima Murthy
- Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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9
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Cao Y, Yan H, Yu G, Su R. Flumazenil-insensitive benzodiazepine binding sites in GABAA receptors contribute to benzodiazepine-induced immobility in zebrafish larvae. Life Sci 2019; 239:117033. [DOI: 10.1016/j.lfs.2019.117033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/16/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
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10
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Zelina EY, Nevolina TA, Sorotskaja LN, Skvortsov DA, Trushkov IV, Uchuskin MG. A General Synthetic Route to Isomeric Pyrrolo[1,2- x][1,4]diazepinones. J Org Chem 2018; 83:11747-11757. [PMID: 30148633 DOI: 10.1021/acs.joc.8b01669] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A simple one-pot method for the synthesis of isomeric pyrrolo[1,2- x][1,4]diazepinones in reasonable yields was developed. The method is based on the condensation of readily available N-Boc amino acids with biomass-derived furans containing aminoalkyl groups followed by deprotection, furan ring opening, and Paal-Knorr cyclization. Using this approach, we synthesized pyrrolo[1,2- a][1,4]diazepin-3(2 H)-ones from furfurylamines and β-amino acids and pyrrolo[1,2- d][1,4]diazepin-4(5 H)-ones from 2-(2-furyl)ethylamines and α-amino acids. The cytotoxicity of the synthesized pyrrolodiazepinones was studied.
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Affiliation(s)
- Elena Y Zelina
- Perm State University , Bukireva st. 15 , Perm , 614990 , Russian Federation
| | - Tatyana A Nevolina
- Perm State University , Bukireva st. 15 , Perm , 614990 , Russian Federation
| | - Ludmila N Sorotskaja
- Kuban State Technological University , Moskovskaya st. 2 , Krasnodar , 350072 , Russian Federation
| | - Dmitry A Skvortsov
- Moscow State University , Leninskie Gory 1-3 , Moscow , 119991 , Russian Federation
| | - Igor V Trushkov
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology , Samory Mashela st. 1 , Moscow , 117997 , Russian Federation.,RUDN University , Miklukho-Maklaya st. 6 , Moscow , 117198 , Russian Federation
| | - Maxim G Uchuskin
- Perm State University , Bukireva st. 15 , Perm , 614990 , Russian Federation
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11
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Vergiftungen mit psychotropen Substanzen. Med Klin Intensivmed Notfmed 2017; 112:557-575. [DOI: 10.1007/s00063-017-0323-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 05/12/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
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12
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Abstract
The most important diagnostic factor in uncovering a toxic etiology for delirium or critical illness is the clinician's openness to the possibility of its existence. Therefore, a consulting psychiatrist, already prepared to perform the detail-oriented work of sorting out behavioral manifestations of disease, can be a vital asset at the bedside if also attuned to the role of purposeful, accidental, and iatrogenic exposures in the intensive care unit. This article summarizes the presentation, evaluation, and treatment of toxidromes relevant to the work of acute psychosomatic medicine.
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Fernandes LCR, Galvão TF, Ricardi AST, Capitani EMD, Hyslop S, Bucaretchi F. Antidote availability in the municipality of Campinas, São Paulo, Brazil. SAO PAULO MED J 2017; 135:15-22. [PMID: 28301629 PMCID: PMC9969729 DOI: 10.1590/1516-3180.2016.00171120816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/12/2016] [Indexed: 03/01/2023] Open
Abstract
CONTEXT AND OBJECTIVE: The lack of availability of antidotes in emergency services is a worldwide concern. The aim of the present study was to evaluate the availability of antidotes used for treating poisoning in Campinas (SP). DESIGN AND SETTING: This was a cross-sectional study of emergency services in Campinas, conducted in 2010-2012. METHODS: The availability, amount in stock, place of storage and access time for 26 antidotal treatments was investigated. In the hospitals, the availability of at least one complete treatment for a 70 kg adult over the first 24 hours of admission was evaluated based on stock and access recommendations contained in two international guidelines. RESULTS: 14 out of 17 functioning emergency services participated in the study, comprising pre-hospital services such as the public emergency ambulance service (SAMU; n = 1) and public emergency rooms for admissions lasting ≤ 24 hours (UPAs; n = 3), and 10 hospitals with emergency services. Six antidotes (atropine, sodium bicarbonate, diazepam, Phytomenadione, flumazenil and calcium gluconate) were stocked in all the services, followed by 13 units that also stocked activated charcoal, naloxone and diphenhydramine or biperiden. No service stocked all of the recommended antidotes; only the regional Poison Control Center had stocks close to recommended (22/26 antidotal treatments). The 10 hospitals had almost half of the antidotes for starting treatments, but only one quarter of the antidotes was present with stocks sufficient for providing treatment for 24 hours. CONCLUSION: The stock of antidotes for attending poisoning emergencies in the municipality of Campinas is incomplete and needs to be improved.
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Affiliation(s)
| | - Taís Freire Galvão
- BPharm, MSc, PhD. Professor, School of Pharmaceutical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil, and Professor, Postgraduate Pharmaceutical Sciences Program, Universidade Federal do Amazonas (UFAM), Manaus (AM), Brazil.
| | - Adriana Safioti Toledo Ricardi
- RN, MSc. Nurse, Campinas Poison Control Center, School of Medical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil.
| | - Eduardo Mello De Capitani
- MD, MSc, PhD. Professor, Campinas Poison Control Center, and Professor, Department of Clinical Medicine, School of Medical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil.
| | - Stephen Hyslop
- BSc, PhD. Professor, Campinas Poison Control Center, and Professor, Department of Pharmacology, School of Medical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil.
| | - Fábio Bucaretchi
- MD, MSc, PhD. Professor, Campinas Poison Control Center, and Professor, Department of Pediatrics, School of Medical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil.
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Ulu A, Inceoglu B, Yang J, Singh V, Vito S, Wulff H, Hammock BD. Inhibition of soluble epoxide hydrolase as a novel approach to high dose diazepam induced hypotension. ACTA ACUST UNITED AC 2016; 6. [PMID: 28255523 DOI: 10.4172/2161-0495.1000300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Hypotension is one of the dose limiting side effects of benzodiazepines (BZDs), in particular of diazepam (DZP) which is still widely used in the clinic. Currently, only one FDA approved antidote exists for BZD overdose and novel approaches are needed to improve management of DZP overdose, dependency and withdrawal. OBJECTIVE Here, we hypothesized that increasing bioactive lipid mediators termed epoxy fatty acids (EpFAs) will prevent hypotension, as was shown previously in a murine model of LPS-induced hypotension. Therefore, we first characterized the time and dose dependent profile of DZP induced hypotension in mice, and then investigated the reversal of the hypotensive effect by inhibiting the soluble epoxide hydrolase (sEH), an enzyme that regulates the levels of EpFAs. MATERIALS AND METHODS Following baseline systolic BP recording using tail cuffs, mice were administered a sEH inhibitor (TPPU) before DZP and BP was monitored. Blood and brain levels of DZP and TPPU were quantified to examine distribution and metabolism. Plasma EpFAs levels were quantified to determine TPPU target engagement. RESULTS In this murine model, DZP induced dose dependent hypotension which was more severe than midazolam. The temporal profile was consistent with the reported pharmacokinetics/pharmacodynamics of DZP. Treatment with TPPU reversed the hypotension resulting from high doses of DZP and decreased the sEH metabolites of EpFAs in the plasma demonstrating target engagement. DISCUSSION AND CONCLUSION Overall, these findings demonstrate the similarity of a murine model of DZP induced hypotension to clinical observations in humans. Furthermore, we demonstrate that stabilization of EpFAs by inhibiting sEH is a novel approach to overcome DZP-induced hypotension and this beneficial effect can be enhanced by an omega three diet probably acting through epoxide metabolites of the fatty acids.
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Affiliation(s)
- Arzu Ulu
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, USA
| | - Bora Inceoglu
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, USA
| | - Jun Yang
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, USA
| | - Vikrant Singh
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Stephen Vito
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, USA
| | - Heike Wulff
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Bruce D Hammock
- Department of Entomology and Nematology, and Comprehensive Cancer Center, University of California, Davis, USA
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15
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Sivilotti MLA. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016; 81:428-36. [PMID: 26469689 PMCID: PMC4767210 DOI: 10.1111/bcp.12731] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 01/14/2023] Open
Abstract
Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.
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Affiliation(s)
- Marco L A Sivilotti
- Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Ontario, Canada
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16
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Abstract
New drugs of abuse continue to emerge, including synthetic cannabinoids, synthetic cathinones, and hallucinogens. It is important to recognize their individual psychopharmacologic properties, symptoms of intoxication, and symptoms of withdrawal. Providers must be vigilant of acute medical or psychiatric complications that may arise from use of these substances. Treatment of the patient also includes recognition of any substance use disorders as well as comorbid psychiatric disorders. Although pharmacologic treatments for substance use disorder (of the drugs included in this article) are limited, there are a variety of psychotherapeutic modalities that may be of some benefit.
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Metzner J, Domino KB. Moderate Sedation: A Primer for Perioperative Nurses. AORN J 2015; 102:526-35. [DOI: 10.1016/j.aorn.2015.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/02/2015] [Indexed: 11/15/2022]
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Martínez Sánchez L, Almario Hernández A, Escuredo Argullós L, Maçao P, Trenchs Sainz de la Maza V, Luaces Cubells C. Uso de antídotos en un servicio de urgencias pediátricas. An Pediatr (Barc) 2014; 81:220-5. [DOI: 10.1016/j.anpedi.2013.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/30/2013] [Accepted: 12/02/2013] [Indexed: 11/30/2022] Open
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19
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Martínez Sánchez L, Almario Hernández A, Escuredo Argullós L, Maçao P, Trenchs Sainz de la Maza V, Luaces Cubells C. Antidote use in a paediatric emergency department. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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20
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Hruby K. [Antidotes in clinical toxicology]. Med Klin Intensivmed Notfmed 2013; 108:465-70. [PMID: 23921789 DOI: 10.1007/s00063-013-0221-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/01/2013] [Indexed: 11/29/2022]
Abstract
This overview describes antidotes, and their clinical pharmacology, that have an established significance in the currently practiced clinical toxicology because of their proven effectiveness in the treatment of serious poisonings. For the proper, efficient, and targeted use of an antidote, pharmacological knowledge is required, which is a central subject of this article. Current data from the literature are used as reference along with the accumulated experiences about possible adverse effects in order to include them in therapeutic considerations. The dosage of antidotes is the subject of several other review articles and is therefore not included in this synopsis.
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Affiliation(s)
- K Hruby
- Vergiftungsinformationszentrale, Gesundheit Österreich GmbH, Stubenring 6, 1010, Wien, Österreich,
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21
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Barry JD, Wills BK. Neurotoxic emergencies. Psychiatr Clin North Am 2013; 36:219-44. [PMID: 23688689 DOI: 10.1016/j.psc.2013.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article is intended for clinicians treating neurotoxic emergencies. Presented are causative agents of neurotoxic emergencies, many of which are easily mistaken for acute psychiatric disorders. Understanding the wide variety of agents responsible for neurotoxic emergencies and the neurotransmitter interactions involved will help the psychiatrist identify and treat this challenging population.
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Affiliation(s)
- J Dave Barry
- Emergency Medicine Residency Program, Naval Medical Center Portsmouth, Portsmouth, VA, USA.
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22
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Lund C, Drottning P, Stiksrud B, Vahabi J, Lyngra M, Ekeberg I, Jacobsen D, Hovda KE. A one-year observational study of all hospitalized acute poisonings in Oslo: complications, treatment and sequelae. Scand J Trauma Resusc Emerg Med 2012; 20:49. [PMID: 22828054 PMCID: PMC3413541 DOI: 10.1186/1757-7241-20-49] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/24/2012] [Indexed: 11/17/2022] Open
Abstract
Objectives Changes in poisoning trends may affect both complications and outcomes in patients with acute poisoning. This study reports the treatments given and the frequency of complications, also related to treatment, mortality and sequelae related to various toxic agents. Methods All acute poisonings in adults (≥16 years) admitted to the five hospitals in Oslo were included consecutively during one year (2008 to 2009) in an observational cross-sectional multicenter study. A standardized form was completed by the treating physician, which covered the study aims. Results There were 1065 admissions in 912 patients. The median length of hospital stay was one day, and 49% were observed in an intensive care unit (ICU). Active treatment was given to 83%, and consisted of supportive therapy (70%), antidote(s) (38%), activated charcoal (16%) and gastric lavage (9%). The most commonly used antidotes were flumazenil (19%), naloxone (17%) and N-acetylcysteine (11%). The rate of treatment-related complications was 2.4% (21/884). Neither flumazenil, naloxone, nor the combination, was associated with convulsions or other complications. Among those receiving N-acetylcysteine, 5% (6/120) developed allergic reactions, one of which mandated discontinuation of treatment. Nineteen percent presented in a coma. Complications developed in 30%, compared with 18% in a 2003 study, mainly respiratory depression (12%), prolonged QTc interval (6%) and hypotension (5%). Eight patients died (0.8%) and five (0.5%) survived with permanent sequelae, mainly anoxic brain damage. Discussion Few patients stayed more than two days. The use of the ICU was liberal, considering that only one out of five presented in a coma. Antidotes were frequently given diagnostically. Although N-acetylcysteine induced allergic reactions, most were mild and treatment discontinuation was only necessary once. The frequency of complications had almost doubled in five years, although the poisoning pattern was largely unchanged. However, few patients developed permanent sequelae.
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Affiliation(s)
- Cathrine Lund
- Department of Acute Medicine, Oslo University Hospital Ullevaal, Kirkeveien 166, Oslo (0407), Norway
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Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm 2012; 69:199-212. [PMID: 22261941 DOI: 10.2146/ajhp110014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use. SUMMARY Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability. CONCLUSION Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.
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Affiliation(s)
- Jeanna M Marraffa
- Upstate New York Poison Center, 750 East Adams Street, Syracuse, NY 13210, USA.
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Abstract
GABA is the major inhibitory neurotransmitter in the adult mammalian CNS. The ionotropic GABA type A receptors (GABA(A)Rs) belong to the Cys-loop family of receptors. Each member of the family is a large pentameric protein in which each subunit traverses the cell membrane four times. Within this family, the GABA type A receptors are particularly important for their rich pharmacology as they are targets for a range of therapeutically important drugs, including the benzodiazepines, barbiturates, neuroactive steroids and anesthetics. This review discusses new insights into receptor properties that allow us to begin to relate the structure of an individual receptor to its functional and pharmacological properties.
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van Hoving D, Veale D, Müller G. WITHDRAWN: Emergency management of acute poisoning. Afr J Emerg Med 2011. [DOI: 10.1016/j.afjem.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Solhi H, Mostafazadeh B, Reza Khoddami Vishteh H, Reza Ghezavati A, Shooshtarizadeh A. Benefit effect of naloxone in benzodiazepines intoxication: Findings of a preliminary study. Hum Exp Toxicol 2010; 30:535-40. [DOI: 10.1177/0960327110374972] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Naloxone, as a low-priced and available drug, may be useful in improvement of signs and symptoms of benzodiazepines intoxication. The aim of this study was assessment of its effect on benzodiazepines poisoning. Methods: In this clinical-trial study, patients with typical signs and symptoms of benzodiazepines poisoning, who were referred to a poisoning center in Tehran in 2008, were selected. After recording of patients’ characteristics, supportive treatment was initiated and patients were randomly assigned to the case group with intravenous (IV) injection of two 0.4 mg naloxone ampules or to the control group. Their signs and symptoms were evaluated again 0.5 hour later. Each of diazepam, clonazepam and alperazolam drug group had 30 patients and lorazepam drug group had 26 patients, half of which patients in each drug group received naloxone. Results: Most of the participants were female and the mean age was 28 years. There were no significant differences between case and control groups in age, sex, time of drug consumption, tablet counts, signs and symptoms and level of consciousness at the admission time in each drug types. After naloxone injection in case groups, all signs and symptoms significantly improved in all drug types in comparison to control groups except nystagmus. In addition, level of consciousness significantly improved in case groups in all drug types except lorazepam. Conclusion: Findings of the study showed that naloxone is effective in management of benzodiazepines poisoning. However, future clinical trials with greater sample size are recommened.
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Affiliation(s)
- Hassan Solhi
- Arak University of Medical Sciences, Arak, Iran,
| | - Babak Mostafazadeh
- Loghman Hakim Poison Hospital, Department of Medical Toxicology & Forensic Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scand J Trauma Resusc Emerg Med 2009; 17:29. [PMID: 19563673 PMCID: PMC2720377 DOI: 10.1186/1757-7241-17-29] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Accepted: 06/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians are often challenged to manage critically ill poison patients. The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient. The goal of this article is to introduce the basic concepts for evaluation of poisoned patients and review the appropriate management of such patients based on the currently available literature. METHODS An unsystematic review of the medical literature was performed and articles pertaining to human poisoning were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION If a poisoning is recognized early and appropriate testing and supportive care is initiated rapidly, the majority of patient outcomes will be good. Judicious use of antidotes should be practiced and clinicians should clearly understand the indications and contraindications of antidotes prior to administration.
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Affiliation(s)
- Jennifer S Boyle
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
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Oray NC, Hocaoglu N, Oray D, Demir O, Atilla R, Tuncok Y. Sedative-Hypnotic Medication Exposures and Poisonings in Izmir, Turkey*. Basic Clin Pharmacol Toxicol 2008; 103:380-5. [DOI: 10.1111/j.1742-7843.2008.00303.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
Emergency physicians are regularly called on to care for critically poisoned patients. This article reviews the general approach and management of the critically poisoned patient. Specific clinical characteristics are identified that may clue the clinician into a specific toxin class as a diagnosis. Appropriate testing in the poisoned patient is reviewed. Complications of poisoning that may bring a rapid demise of the critically ill poisoned patient are highlighted and the management of those complications is discussed.
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Criminal poisoning of commuters in Bangladesh: Prospective and retrospective study. Forensic Sci Int 2008; 180:10-6. [DOI: 10.1016/j.forsciint.2008.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Revised: 01/10/2008] [Accepted: 06/18/2008] [Indexed: 11/21/2022]
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Indicadores de calidad para la asistencia urgente de pacientes con intoxicaciones agudas (Calitox-2006). ACTA ACUST UNITED AC 2008; 23:173-91. [DOI: 10.1016/s1134-282x(08)72131-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Leggio L, Kenna GA, Swift RM. New developments for the pharmacological treatment of alcohol withdrawal syndrome. A focus on non-benzodiazepine GABAergic medications. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:1106-17. [PMID: 18029075 DOI: 10.1016/j.pnpbp.2007.09.021] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 09/07/2007] [Accepted: 09/29/2007] [Indexed: 01/22/2023]
Abstract
Alcohol withdrawal syndrome (AWS) can be a life-threatening condition affecting some alcohol-dependent patients who abruptly discontinue or decrease their alcohol consumption. The main objectives of the clinical management of AWS include: to decrease the severity of symptoms, prevent more severe withdrawal clinical manifestations and facilitate entry of the patient into a treatment program in order to attempt to achieve and maintain long-term abstinence from alcohol. At present, benzodiazepines represent the drugs of choice in the treatment of AWS. However, in line with the possible side effects and addictive properties related to benzodiazepine use, there is growing evidence to suggest that non-benzodiazepine GABAergic compounds represent promising medications in the treatment of alcohol-dependent patients. This review focuses on research into non-benzodiazepine GABAergic medications for the treatment of AWS. Among them, carbamazepine, gabapentin and valproic acid are the most studied. The studies on carbamazepine seem to be the most compelling. Preliminary data have also suggested the possible utility of baclofen and topiramate, although further evidence is needed. The promising results in terms of both safety and efficacy are reported. However, we also note the need of more methodologically controlled studies on a greater number of patients, involving more complicated forms of AWS.
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Affiliation(s)
- Lorenzo Leggio
- Center for Alcohol and Addiction Studies, Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI 02912, USA.
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Abstract
Toxicologic conditions are encountered in critically ill patients due to intentional or unintentional misuse of or exposure to therapeutic or illicit drugs. Additionally, toxicities related to medical interventions may develop in hospitalized patients. This review focuses on recent developments in the field of critical care toxicology. Early interventions to decrease absorption or enhance elimination of toxins have limited value. Specific interventions to manage toxicities due to analgesics, sedative-hypnotics, antidepressants, antipsychotics, cardiovascular agents, alcohols, carbon monoxide, and cholinergic agents are reviewed. Hospital-acquired toxicities due to methemoglobinemia, propylene glycol, and propofol should be recognized and treated. The clinician is continually required to incorporate clinical judgment along with available scientific data and clinical evidence to determine the best therapy for toxicologic conditions.
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Zimmerman JL, Rudis M. Poisonings. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Drug- and toxin-associated seizures (DTS) may result from exposure to a wide variety of agents. Most DTS can be managed with supportive care. First-line anticonvulsant therapy should include benzodiazepines, unless agents require a specific antidote. Phenytoin is generally not expected to be useful for DTS and in some instances may be harmful. In this article the authors discuss the pathophysiology of DTS, the potential differential diagnosis, and the clinical presentation. They also review selected agents that cause DTS and provide an overview of how the clinician should approach the management of patients who have DTS.
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Abstract
Drug- and toxin-associated seizures may result from exposure to a wide variety of agents. Obtaining a comprehensive history behind the exposure is generally more helpful than diagnostic testing. Most DTS may be managed with supportive care, including benzodiazepines, except in the case of agents that require a specific intervention or antidote.
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Affiliation(s)
- Brandon Wills
- Department of Emergency Medicine, University of Illinois, Chicago, Chicago, IL 60612, USA.
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McKenzie CA, McKinnon W, Naughton DP, Treacher D, Davies G, Phillips GJ, Hilton PJ. Differentiating midazolam over-sedation from neurological damage in the intensive care unit. Crit Care 2005; 9:R32-6. [PMID: 15693964 PMCID: PMC1065106 DOI: 10.1186/cc3010] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2004] [Accepted: 11/02/2004] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Midazolam is used routinely to sedate patients in the intensive care unit (ICU). We suspected that midazolam over-sedation was occurring in the ICU of the Guy's and St. Thomas' Trust and that it could be difficult to differentiate this from underlying neurological damage. A sensitive assay for detecting midazolam and 1-hydroxymidazolam glucuronide (1-OHMG) in serum was developed and applied in the clinical setting. METHODS In the present study we evaluated a series of cases managed in a mixed medical, surgical and trauma ICU. Serum was collected from 26 patients who received midazolam, were 'slow to wake' and in whom there was suspicion of neurological damage. Patient outcome was followed in terms of mortality, neurological recovery and neurological damage on discharge. RESULTS Out of 26 patients, 13 had detectable serum levels of midazolam and/or 1-OHMG after a median of 67 hours (range 36-146 hours) from midazolam cessation. Of these 13 patients in whom midazolam/1-OHMG was detectable, 10 made a full neurological recovery. Of the remaining 13 patients with no detectable midazolam/1-OHMG, three made a full neurological recovery; 10 patients were subsequently found to have suffered neurological damage (P < 0.002), eight of whom died and two were discharged from the ICU with profound neurological damage. CONCLUSION These findings confirm that prolonged sedation after midazolam therapy should be considered in the differential diagnosis of neurological damage in the ICU. This can be reliably detected by the assay method described. The effects of midazolam/1-OHMG persist days after administration of midazolam has ceased. After prolonged sedation has been excluded in this patient group, it is highly likely that neurological damage has occurred.
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Affiliation(s)
- Catherine A McKenzie
- Senior Pharmacist, Intensive Care Medicine, Department of Pharmacy, Guy's and St. Thomas' Hospital, London, UK
| | - William McKinnon
- Senior Scientist, Renal Laboratory, St. Thomas' Hospital, London, UK
| | - Declan P Naughton
- Senior Lecturer, School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK
| | - David Treacher
- Consultant Intensivist, Intensive Care Unit, Guy's and St. Thomas' NHS Trust, London, UK
| | - Graham Davies
- Academic Director of Clinical Studies, School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK
| | - Gary J Phillips
- Research Fellow, School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton, UK
| | - Philip J Hilton
- Director of the Renal Laboratory, Intensive Care Unit, Guy's and St. Thomas' NHS Trust, London, UK
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