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Cardiac complications in amitriptyline poisoning: Successful treatment with physostigmine
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Abstractsl
peter Rosen, M D - - e d i t o r
professor of Emergency Medicine and Director of the Division of Emergency Medicine, university of Chicago Hospitals and Clinics
Beverly Fauman,
MD -- assistant editor
Assistant Professor of Emergency Medicine and Psychiatry, University of Chicago Hospitals and Clinics current status of diagnosis and management of strangulation obstruction of the small bowel. Shatila AH, Chamberlain BE, Webb WR, Am J Surg (Sept) 1976. The presence of strangulated bowel increases by threefold the overall mortality of patients with intestinal obstruction, and increases the likelihood of shock (hypovolemic a n d septic), peritonitis and sepsis. However, a retrospective review of 103 cases of acute mechanical small bowel obstruction found no clinical sign or laboratory test t h a t differentiated simple (nonstrangulated) from strangulated obstruction. The classic signs of strangulation - - fever, tachycardia and leukocytosis - - were not predictive and were especially misleading in patients older t h a n 50 years. The abdominal examination, plain and contrast x-ray studies, and serum levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT) and amylase were equally unhelpful. Although abdominal wall rigidity, hypothermia and occult rectal bleeding were only seen in patients with strangulation obstruction, they were late findings and not helpful in making an early diagnosis. In this series, most cases of strangulation were associated with femoral hernias; others were less commonly associated with internal and inguinal hernias and postoperative adhesions. Simple.obstruction was most often associated with postoperative adhesions, and less often with intra-abdominal m a l i g n a n c i e s (ovarian and colorectal) and femoral and inguinal hernias. The authors recommended early laparotomy for all patients with acute mechanical small bowel obstruction as the only therapy at present to decrease the mortality of this entity. (Editor's note: We have found a helpful clinical clue to be the change from intermittent to constant abdominal pain. In the older patient, a differential shift is often present without leukocytosis. This remains a difficult diagnostic entity for the emergency physician and far too often obstruction is fobbed off as gastroenteritis. We again emphasize the diagnostic triad of pain, nausea and vomiting, and prior surgery.)
Michael D. McGehee, MD
intestinal obstruction, strangulated bowel Cardiac complications in amitriptyline poisoning: successful treatment with physostigmine. Tobis J, Das BN, JAMA 235:1474-1476, (April) 1976. Physostigmine has been used successfully to treat the central nervous system effects of tricyclic antidepressants such as agitation, seizures and coma, as well as their peripheral effects such as tachycardia. Physostigmine (22 mg over 48 hours) was used to successfully treat some of the more severe cardiac complications induced by amitriptyline hydrochloride, such as abnormal Conduction pathways, A-V dissociation, and ventricular tachyCardia. Following one dose of physostigmine, the patient deloped a generalized tonic-clonic seizure reaffi1:ming the fact nat physostigmine itself is not an innocuous drug. (Editor's note: When faced with heart block, the natural tendency is to reach for atropine. This will be disastrous in the face o f this nd of anticholinergic poisoning. A m o n g drugs for overdos¢~,y e tricyclic antidepressants certainly provide a dangerou s choice ' for the depressed patient_) Vincent Markovchiclq MD
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Physostigmine, amitriptyline poisoning
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6:3 (Mar) 1977
Bacteriologic diagnosis of acute pneumonia. Davidson M, Tempest B, Palmer DL, JAMA 235:158-163, (Jan) 1976. The authors compare the diagnostic value of sputum, blood, tracheal aspirate, and lung aspirate cultures in 25 patients with pneumonia. Although sputum showed the same isolates that were found in the lung aspirate in 68c~ of patients, it commonly contained additional organisms. Tracheal and lung aspirates demonstrated identical results 41% of the time. Lung aspirates yielded a single isolate in 69% of patients (more frequently Lhan other techniques), and only occasionally multiple organisms. Twenty-seven percent of tracheal aspirates grew multiple potential pathogens, and the data suggests contamination of tracheal aspirates from the upper respiratory tract. Complications for all techniques were few. Nevertheless, the authors feel that lung aspiration should be confined to critically ill but cooperative patients with "accessible roentgenographic infiltrates" and for whom a rapid and precise bacteriologic diagnosis is essential. (Editor's note: The complication rate of lung aspiration is indeed small in experienced hands. However, it is our opinion that this diagnostic maneuver is not indicated in the emergency department. I f sputum gram stain is not enough to give the proper clue for initial therapy, tracheal aspiration is much safer and almost as accurate.) d.B. Franaszek, MD
pneumonia, bacteriologic diagnosis Fetal heart rate patterns preceding death in utero. Cetrulo CL, Schifrin BS, Obstet Gynecol 48:521, (Nov) 1976. Four cases illustrate patterns of fetal heart rate during labor, as recorded by continuous monitoring, preceding the dehvery of stillborn infants. Normally, uterine contractions are associated with a transient deceleration of fetal heart rate. There is also a normal beat-to-beat variability of rate, reflected by rapid, small fluctuations in the baseline of the graph. The important point for the emergency physician is t h a t instantaneous or intermittent stethoscopic auscultation is of little value in assessing the well-being of the fetus, except in extreme cases. P e r s i s t e n t bradycardia, though certainly ominous, is a very late sign. Continuous electrode monitoring is the only means of early detection of fetal heart rate patterns now recognized as indicative of feLal distress in utero. (Editor's note: While few emergency depal"tments are set up to continuously monitor fetal heart ;ones, it is still an important responsibility to listen for them. A Doppler unquestionably can resolve some indistinct tones.)
Jeffrey S. Menkes, MD
heart failure, neonate, EKG The role of thoracic aortic occlusion for massive hemoperitoneum. Ledgerwood AM, Kazmers M, Lucas CE, J Trauma 16:610-615, 1976. In 40 patients with massive hemoperitoneum from abdominal trauma, laparotomy and left thoracotomy were performed in all to control abdominal bleeding (29 with thoracotomy first). Sud-
129/83
Abstractsl
peter Rosen, M D - - e d i t o r
professor of Emergency Medicine and Director of the Division of Emergency Medicine, university of Chicago Hospitals and Clinics
Beverly Fauman,
MD -- assistant editor
Assistant Professor of Emergency Medicine and Psychiatry, University of Chicago Hospitals and Clinics current status of diagnosis and management of strangulation obstruction of the small bowel. Shatila AH, Chamberlain BE, Webb WR, Am J Surg (Sept) 1976. The presence of strangulated bowel increases by threefold the overall mortality of patients with intestinal obstruction, and increases the likelihood of shock (hypovolemic a n d septic), peritonitis and sepsis. However, a retrospective review of 103 cases of acute mechanical small bowel obstruction found no clinical sign or laboratory test t h a t differentiated simple (nonstrangulated) from strangulated obstruction. The classic signs of strangulation - - fever, tachycardia and leukocytosis - - were not predictive and were especially misleading in patients older t h a n 50 years. The abdominal examination, plain and contrast x-ray studies, and serum levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT) and amylase were equally unhelpful. Although abdominal wall rigidity, hypothermia and occult rectal bleeding were only seen in patients with strangulation obstruction, they were late findings and not helpful in making an early diagnosis. In this series, most cases of strangulation were associated with femoral hernias; others were less commonly associated with internal and inguinal hernias and postoperative adhesions. Simple.obstruction was most often associated with postoperative adhesions, and less often with intra-abdominal m a l i g n a n c i e s (ovarian and colorectal) and femoral and inguinal hernias. The authors recommended early laparotomy for all patients with acute mechanical small bowel obstruction as the only therapy at present to decrease the mortality of this entity. (Editor's note: We have found a helpful clinical clue to be the change from intermittent to constant abdominal pain. In the older patient, a differential shift is often present without leukocytosis. This remains a difficult diagnostic entity for the emergency physician and far too often obstruction is fobbed off as gastroenteritis. We again emphasize the diagnostic triad of pain, nausea and vomiting, and prior surgery.)
Michael D. McGehee, MD
intestinal obstruction, strangulated bowel Cardiac complications in amitriptyline poisoning: successful treatment with physostigmine. Tobis J, Das BN, JAMA 235:1474-1476, (April) 1976. Physostigmine has been used successfully to treat the central nervous system effects of tricyclic antidepressants such as agitation, seizures and coma, as well as their peripheral effects such as tachycardia. Physostigmine (22 mg over 48 hours) was used to successfully treat some of the more severe cardiac complications induced by amitriptyline hydrochloride, such as abnormal Conduction pathways, A-V dissociation, and ventricular tachyCardia. Following one dose of physostigmine, the patient deloped a generalized tonic-clonic seizure reaffi1:ming the fact nat physostigmine itself is not an innocuous drug. (Editor's note: When faced with heart block, the natural tendency is to reach for atropine. This will be disastrous in the face o f this nd of anticholinergic poisoning. A m o n g drugs for overdos¢~,y e tricyclic antidepressants certainly provide a dangerou s choice ' for the depressed patient_) Vincent Markovchiclq MD
~
~
Physostigmine, amitriptyline poisoning
~]~)
6:3 (Mar) 1977
Bacteriologic diagnosis of acute pneumonia. Davidson M, Tempest B, Palmer DL, JAMA 235:158-163, (Jan) 1976. The authors compare the diagnostic value of sputum, blood, tracheal aspirate, and lung aspirate cultures in 25 patients with pneumonia. Although sputum showed the same isolates that were found in the lung aspirate in 68c~ of patients, it commonly contained additional organisms. Tracheal and lung aspirates demonstrated identical results 41% of the time. Lung aspirates yielded a single isolate in 69% of patients (more frequently Lhan other techniques), and only occasionally multiple organisms. Twenty-seven percent of tracheal aspirates grew multiple potential pathogens, and the data suggests contamination of tracheal aspirates from the upper respiratory tract. Complications for all techniques were few. Nevertheless, the authors feel that lung aspiration should be confined to critically ill but cooperative patients with "accessible roentgenographic infiltrates" and for whom a rapid and precise bacteriologic diagnosis is essential. (Editor's note: The complication rate of lung aspiration is indeed small in experienced hands. However, it is our opinion that this diagnostic maneuver is not indicated in the emergency department. I f sputum gram stain is not enough to give the proper clue for initial therapy, tracheal aspiration is much safer and almost as accurate.) d.B. Franaszek, MD
pneumonia, bacteriologic diagnosis Fetal heart rate patterns preceding death in utero. Cetrulo CL, Schifrin BS, Obstet Gynecol 48:521, (Nov) 1976. Four cases illustrate patterns of fetal heart rate during labor, as recorded by continuous monitoring, preceding the dehvery of stillborn infants. Normally, uterine contractions are associated with a transient deceleration of fetal heart rate. There is also a normal beat-to-beat variability of rate, reflected by rapid, small fluctuations in the baseline of the graph. The important point for the emergency physician is t h a t instantaneous or intermittent stethoscopic auscultation is of little value in assessing the well-being of the fetus, except in extreme cases. P e r s i s t e n t bradycardia, though certainly ominous, is a very late sign. Continuous electrode monitoring is the only means of early detection of fetal heart rate patterns now recognized as indicative of feLal distress in utero. (Editor's note: While few emergency depal"tments are set up to continuously monitor fetal heart ;ones, it is still an important responsibility to listen for them. A Doppler unquestionably can resolve some indistinct tones.)
Jeffrey S. Menkes, MD
heart failure, neonate, EKG The role of thoracic aortic occlusion for massive hemoperitoneum. Ledgerwood AM, Kazmers M, Lucas CE, J Trauma 16:610-615, 1976. In 40 patients with massive hemoperitoneum from abdominal trauma, laparotomy and left thoracotomy were performed in all to control abdominal bleeding (29 with thoracotomy first). Sud-
129/83