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Effect of doxapram on heavy sedation produced by intravenous diazepam
The Journal of Emergency Medinne, Vol. 1, pp. 283-292, 1984
?N ?ITROUS OXIDE ABUSE: A NEW CAUSE FOR PNEUMOMEDIASTINUM. LiPuma JP, Wellman J, Stern HP. Radiology 1982; 145502. The authors report two cases of pneumomediastinum following inhalation of pressurized nitrous oxide. In both cases, nitrous oxide was inhaled through the use of a “whippet.” The whippet is made from an empty whipped cream dispenser which is filled with pressurized nitrous oxide from 3.5-L cylinders. The gas is then inhaled directly from the nozzle of the whippet. The high-pressure gas causes rupture of the intraalveolar walls, dissects along the bronchovascular tree, and results in clinical pneumomedi[James Berner, MD] astinum. Editor’s Note: As with other causes of pneumomediastinum (eg, marijuana) which have been reported, this too appears to be benign. Nevertheless, inhalation of any gas under pressure can be very dangerous, and perhaps more concern needs to be raised for this form of selfabuse than for other recreational inhalations.
CopyrIght 0 1984 Pergamon Press Ltd
??
ment, diazepam may act as a GABA agonist, restoring central neurochemical balance. [Lily Conrad MD] Editor’s Note: It is of historical interest that at one time strychnine was advocated for the treatment of barbiturate poisoning. Perhaps someday we will understand neurophysiology well enough to be able to recommend the appropriate cocktail of neurotransmitters.
?? ACETAMINOPHEN POISONING IN INFANCY. Greene JW, Craft L, Ghishan F. Am J Dis Child 1983; 137:386-387. Although acetaminophen-induced hepatotoxicity is common in adults and adolescents, due to overdosage, similar degrees of liver damage are relatively rare in young children. The authors report two cases of hepatotoxicity in infants who were given acetaminophen chronically in dosages not usually associated with toxicity. Liver toxicity in both infants was manifest as depressed consciousness, with elevated hepatic enzyme levels and hypoglycemia. The authors postulate that infants given acetaminophen are at risk of developing hepatotoxicity due to the immaturity of the hepatic glucuronide conjugation system. In addition, since there are many proprietary drugs containing acetaminophen as an ingredient, parents may be inadvertently overdosing their children with acetaminophen by treating their child’s “cold” with what they believe are different medications. Acetaminophen toxicity should be considered in the differential diagnosis of infants with evidence of hepatic dysfunction. [James C. Mitchiner, MD]
EISTRYCHNINE POISONING: ABNORMAL EYE MOVEMENTS. Blain P, et al. Clin Toxicol 1982; 19(2):215-217. Poisoning with strychnine often presents with a typical clinical picture, seizure activity, trismus, myoclonic movements, risus sardonicus, and hyperactive tendon reflexes. All these respond to intravenous benzodiazepines. This case report documents an associated horizontal pendular nystagmus in strychnine poisoning, which appeared unaffected by treatment with diazepam (Valium@). The British authors cite evidence that strychnine produces its behavioral effects by centrally antagonizing the effects of the central neurotransmitter y-aminobutyric acid (GABA). GABA may be a synaptic mediator in visual as well as motor pathways. In treat-
=X=X= X=X=X=
Pr~ntd in the USA
?? lEFFECT OF DOXAPRAM ON HEAVY SEDATION PRODUCED BY INTRAVENOUS DIAZEPAM. Allen CJ, Gough KR. Br Med J 1983; 286:1181-1182.
Abstracts-designed to keep readers up to date by providing original abstracts of current literature from all fields relating to emergency medicine-are prepared by the Emergency Medicine Residents of the Denver General, St. Anthony’s, St. Joseph’s, and Porter’s Hospitals, with notes by Peter Rosen, MD, Editor-in-chief of JEM. 0736-4679/84 283
$3.00 + .OO
284
This is a randomized controlled trial to test the effect of doxapram (Dopram@ Injectable) in patients heavily sedated by intravenous diazepam (Valium@). Only patients (115) undergoing endoscopy with intravenous diazepam were studied. All patients were free of significant medical illness and had normal liver function tests. The patients’ respiratory rate, blood pressure, and mental status were assessed prior to sedation. Intravenous diazepam was then given, and the patients randomized to receive either 100 mg of doxapram by IV bolus or an identical placebo. Respiratory rate, blood pressure, and mental status were then reassessed at 5, 60, and 120 minutes. Of the 115 patients, 24 became unexpectedly heavily sedated by the above three criteria. These patients were indistinguishable from the others by health, weight, dose, liver function, or any other measured standards. Thirteen of these patients received doxapram and 11 received placebo. Five minutes after injection there was substantial and statistically significant improvement in mentation, ventilation, visual analog score, and mental arithmetic performance (p
OCORRELATION BETWEEN MANIFESTATIONS OF DIGOXIN TOXICITY AND SERUM DIGOXIN, CALCIUM, POTASSIUM, AND MAGNESIUM CONCENTRATIONS AND ARTERIAL PH. Sonnenblick M, Abraham A, Meshulam Z, Eylath U. Br Med J 1983; 286:1089-1091. Measurement of plasma digoxin levels is widely used as an aid to diagnosing digoxin toxicity. Previous studies, however, have shown the relative unreliability of these levels as a corre-
The Journal of Emergency Medicine
late with clinical toxicity. Digitalis toxicity may be divided into two main types, gastrointestinal and cardiac, and the latter type further divided into groups with increased automaticity and groups with other manifestations, such as bradycardia, AV block, and SVT with block. Ninety-six patients who presented to the department of medicine with signs or symptoms of digitalis toxicity were studied. Patients with undetectable digoxin levels and those whose symptoms did not clear after three days withholding of digoxin were subsequently excluded. Fifty-two patients were able to be included in the study. Sixty-nine patients who were receiving digoxin but had no signs or symptoms of toxicity were also included. Patients were separated into automaticity, “block,” and gastrointestinal (GI) groups as above. Patients with Cl manifestations had toxic digoxin levels but normal arterial pH and calcium/potassium ratios. Conversely, patients with drug-induced automaticity had normal digoxin levels but their mean calcium/potassium ratios and mean arterial pH values differed from those with Cl symptoms @ < 0.01). The “block” patients also differed significantly from the automaticity group, especially in that their Ca/K ratio was lower, comparable to that of the GI group. The authors conclude that the relative balance between Ca and K determines the potential for digitalis to produce automaticity but that this mechanism is not important in the GI or nonautomaticity cardiotoxic effects. They suggest that measurement of free ionized calcium and calculation of the Ca/K ratio may be of diagnostic value in suspected digitalis induced automaticity. [Ron M. Walls, MD]
?? DEMONSTRATION OF IgE AND IgG ANTIBODIES AGAINST VENOMS IN THE BLOOD OF VICTIMS OF FATAL STING ANAPHYLAXIS. Hoffman DR, Wood CL, Hudson P. J Allergy Clin Immunol 1983; 71: 193-196. Postmortem serum was obtained from eight of the nine reported cases of fatal hymenoptera sting anaphylaxis occurring in North Carolina during the period 1979-1981. These sera were tested quantitatively for IgG antivenom antibodies by the enzyme-lined immunosorbent assay (ELISA) and for five specific IgE antibodies by the Radioallergosorbent test (RAST). IgG levels in these eight cases were similar to those in a population known to be sensitive to hymenoptera stings, but not yet treated. Levels
?N ?ITROUS OXIDE ABUSE: A NEW CAUSE FOR PNEUMOMEDIASTINUM. LiPuma JP, Wellman J, Stern HP. Radiology 1982; 145502. The authors report two cases of pneumomediastinum following inhalation of pressurized nitrous oxide. In both cases, nitrous oxide was inhaled through the use of a “whippet.” The whippet is made from an empty whipped cream dispenser which is filled with pressurized nitrous oxide from 3.5-L cylinders. The gas is then inhaled directly from the nozzle of the whippet. The high-pressure gas causes rupture of the intraalveolar walls, dissects along the bronchovascular tree, and results in clinical pneumomedi[James Berner, MD] astinum. Editor’s Note: As with other causes of pneumomediastinum (eg, marijuana) which have been reported, this too appears to be benign. Nevertheless, inhalation of any gas under pressure can be very dangerous, and perhaps more concern needs to be raised for this form of selfabuse than for other recreational inhalations.
CopyrIght 0 1984 Pergamon Press Ltd
??
ment, diazepam may act as a GABA agonist, restoring central neurochemical balance. [Lily Conrad MD] Editor’s Note: It is of historical interest that at one time strychnine was advocated for the treatment of barbiturate poisoning. Perhaps someday we will understand neurophysiology well enough to be able to recommend the appropriate cocktail of neurotransmitters.
?? ACETAMINOPHEN POISONING IN INFANCY. Greene JW, Craft L, Ghishan F. Am J Dis Child 1983; 137:386-387. Although acetaminophen-induced hepatotoxicity is common in adults and adolescents, due to overdosage, similar degrees of liver damage are relatively rare in young children. The authors report two cases of hepatotoxicity in infants who were given acetaminophen chronically in dosages not usually associated with toxicity. Liver toxicity in both infants was manifest as depressed consciousness, with elevated hepatic enzyme levels and hypoglycemia. The authors postulate that infants given acetaminophen are at risk of developing hepatotoxicity due to the immaturity of the hepatic glucuronide conjugation system. In addition, since there are many proprietary drugs containing acetaminophen as an ingredient, parents may be inadvertently overdosing their children with acetaminophen by treating their child’s “cold” with what they believe are different medications. Acetaminophen toxicity should be considered in the differential diagnosis of infants with evidence of hepatic dysfunction. [James C. Mitchiner, MD]
EISTRYCHNINE POISONING: ABNORMAL EYE MOVEMENTS. Blain P, et al. Clin Toxicol 1982; 19(2):215-217. Poisoning with strychnine often presents with a typical clinical picture, seizure activity, trismus, myoclonic movements, risus sardonicus, and hyperactive tendon reflexes. All these respond to intravenous benzodiazepines. This case report documents an associated horizontal pendular nystagmus in strychnine poisoning, which appeared unaffected by treatment with diazepam (Valium@). The British authors cite evidence that strychnine produces its behavioral effects by centrally antagonizing the effects of the central neurotransmitter y-aminobutyric acid (GABA). GABA may be a synaptic mediator in visual as well as motor pathways. In treat-
=X=X= X=X=X=
Pr~ntd in the USA
?? lEFFECT OF DOXAPRAM ON HEAVY SEDATION PRODUCED BY INTRAVENOUS DIAZEPAM. Allen CJ, Gough KR. Br Med J 1983; 286:1181-1182.
Abstracts-designed to keep readers up to date by providing original abstracts of current literature from all fields relating to emergency medicine-are prepared by the Emergency Medicine Residents of the Denver General, St. Anthony’s, St. Joseph’s, and Porter’s Hospitals, with notes by Peter Rosen, MD, Editor-in-chief of JEM. 0736-4679/84 283
$3.00 + .OO
284
This is a randomized controlled trial to test the effect of doxapram (Dopram@ Injectable) in patients heavily sedated by intravenous diazepam (Valium@). Only patients (115) undergoing endoscopy with intravenous diazepam were studied. All patients were free of significant medical illness and had normal liver function tests. The patients’ respiratory rate, blood pressure, and mental status were assessed prior to sedation. Intravenous diazepam was then given, and the patients randomized to receive either 100 mg of doxapram by IV bolus or an identical placebo. Respiratory rate, blood pressure, and mental status were then reassessed at 5, 60, and 120 minutes. Of the 115 patients, 24 became unexpectedly heavily sedated by the above three criteria. These patients were indistinguishable from the others by health, weight, dose, liver function, or any other measured standards. Thirteen of these patients received doxapram and 11 received placebo. Five minutes after injection there was substantial and statistically significant improvement in mentation, ventilation, visual analog score, and mental arithmetic performance (p
OCORRELATION BETWEEN MANIFESTATIONS OF DIGOXIN TOXICITY AND SERUM DIGOXIN, CALCIUM, POTASSIUM, AND MAGNESIUM CONCENTRATIONS AND ARTERIAL PH. Sonnenblick M, Abraham A, Meshulam Z, Eylath U. Br Med J 1983; 286:1089-1091. Measurement of plasma digoxin levels is widely used as an aid to diagnosing digoxin toxicity. Previous studies, however, have shown the relative unreliability of these levels as a corre-
The Journal of Emergency Medicine
late with clinical toxicity. Digitalis toxicity may be divided into two main types, gastrointestinal and cardiac, and the latter type further divided into groups with increased automaticity and groups with other manifestations, such as bradycardia, AV block, and SVT with block. Ninety-six patients who presented to the department of medicine with signs or symptoms of digitalis toxicity were studied. Patients with undetectable digoxin levels and those whose symptoms did not clear after three days withholding of digoxin were subsequently excluded. Fifty-two patients were able to be included in the study. Sixty-nine patients who were receiving digoxin but had no signs or symptoms of toxicity were also included. Patients were separated into automaticity, “block,” and gastrointestinal (GI) groups as above. Patients with Cl manifestations had toxic digoxin levels but normal arterial pH and calcium/potassium ratios. Conversely, patients with drug-induced automaticity had normal digoxin levels but their mean calcium/potassium ratios and mean arterial pH values differed from those with Cl symptoms @ < 0.01). The “block” patients also differed significantly from the automaticity group, especially in that their Ca/K ratio was lower, comparable to that of the GI group. The authors conclude that the relative balance between Ca and K determines the potential for digitalis to produce automaticity but that this mechanism is not important in the GI or nonautomaticity cardiotoxic effects. They suggest that measurement of free ionized calcium and calculation of the Ca/K ratio may be of diagnostic value in suspected digitalis induced automaticity. [Ron M. Walls, MD]
?? DEMONSTRATION OF IgE AND IgG ANTIBODIES AGAINST VENOMS IN THE BLOOD OF VICTIMS OF FATAL STING ANAPHYLAXIS. Hoffman DR, Wood CL, Hudson P. J Allergy Clin Immunol 1983; 71: 193-196. Postmortem serum was obtained from eight of the nine reported cases of fatal hymenoptera sting anaphylaxis occurring in North Carolina during the period 1979-1981. These sera were tested quantitatively for IgG antivenom antibodies by the enzyme-lined immunosorbent assay (ELISA) and for five specific IgE antibodies by the Radioallergosorbent test (RAST). IgG levels in these eight cases were similar to those in a population known to be sensitive to hymenoptera stings, but not yet treated. Levels