Archive for the ‘tox’ Category

Avoid Alcohol Withdrawal Admissions

January 28th, 2016
by reuben in tox

    Alcoholic patients are predisposed to many dangerous conditions and present an array of management challenges for emergency providers, however at many centers, some of these patients present with uncomplicated alcohol intoxication and end up admitted for alcohol withdrawal. This serves no one’s interests because alcohol withdrawal is a condition that generally does not benefit from inpatient management; detoxification proceeds over several days and the patient is discharged, unfortunately often to resume drinking, no better off than before. Though some alcoholics present in advanced withdrawal, requiring aggressive management and an ICU or step-down bed, many (most?) patients admitted for alcohol withdrawal present to the ED intoxicated and develop withdrawal in the department. Admitting this group is at best pointless and usually avoidable. There’s a lot of literature and discussion around treating alcohol withdrawal, but very little on how to prevent it, which perhaps is part of the problem. The first step is to identify patients at risk for withdrawal. The most obvious risk factor is a history of alcohol withdrawal, especially prior admission for alcohol withdrawal; ideally these patients would be flagged at triage. Anyone who drinks every day is at risk, though. Most at-risk patients arrive to the ED drunk, but if a daily drinker presents not drunk (i.e. comes with some other concern) or is in early withdrawal, promptly dose librium and reassess. Intoxicated alcoholics at risk for withdrawal should be reassessed frequently for alertness. Once the sobering alcoholic is alert he is at risk for withdrawal and the most pressing concern is whether he can be safely discharged. If yes, discharge.*  If…

Another myth we can put to rest. Of 161 patients with digoxin toxicity in one hospital over 17.5 years, 23 received calcium, and no one developed stone heart, whatever the hell that is. Pretty easy study to do, but probably the best data we’ll have on this subject. So give your calcium while you’re getting your hands on and preparing digibind. Levine M, Nikkanen H, Pallin D. The effects of intravenous calcium in patients with digoxin toxicity. Journal of Emergency Medicine. 2011; 40(1):41-46. Background: Digoxin is an inhibitor of the sodium-potassium ATPase. In overdose, hyperkalemia is common. Although hyperkalemia is often treated with intravenous calcium, it is traditionally contraindicated in digoxin toxicity. Objectives: To analyze records from patients treated with intravenous calcium while digoxin-toxic. Methods: We reviewed the charts of all adult patients diagnosed with digoxin toxicity in a large teaching hospital over 17.5 years. The main outcome measures were frequency of life-threatening dysrhythmia within 1 h of calcium administration, and mortality rate in patients who did vs. patients who did not receive intravenous calcium. We use multivariate logistic regression to ensure that no relationship was overlooked due to negative confounders (controlling for age, creatinine, systolic blood pressure, peak serum potassium, time of development of digoxin toxicity, and digoxin concentration). Results: We identified 161 patients diagnosed with digoxin toxicity, and were able to retrieve 159 records. Of these, 23 patients received calcium. No life-threatening dysrhythmias occurred within 1 h of calcium administration. Mortality was similar among those who did not receive calcium (27/136, 20%) compared…

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