- Email: [email protected]
Response from Drs. Welch and Todd
The Journal of Emergency
Medicine,
Vol. 9, pp. 153-I 56 1991
Printed in the USA
I-J Nifedipine
* Copyright
0 1991 Pergamon Press plc
situation cannot be recommended both because of the real risk of aspiration, and because of the theoretical risk of exacerbation of the heart block and hypotension caused by the increased vagal tone that accompanies emesis. Knowing that under ideal circumstances only about 38% of drug can be recovered in ipecac-induced emesis (5), we must assess the likelihood of recovering toxin that could not be recovered with four episodes of spontaneous emesis and weigh this potential benefit against the risks of aspiration and exacerbation of heart block.
I read with great concern the case of nifedipine overdose presented by Welch and Todd (1). Although the title implies that both ethanol intoxication and the patient’s underlying congenital heart disease contributed to her morbidity, the authors acknowledge that neither factor appeared to alter either their management, or the subsequent outcome of this case. Furthermore, the authors allege that nifedipine overdose is a rarely reported occurrence. In addition to the three citations given in the text, three fatalities have been reported in the recent national data reports from the American Association of Poison Control Centers (AAPCC) (2,3). Regardless of the frequency of previous citations, one would hope that the publication of this case could add to our collective understanding of nifedipine overdose. It is naive to assume that nifedipine has never been taken in combination with ethanol. It is well accepted that ethanol is a factor in approximately 35% of suicide attempts (4). It would be reasonable to assume that in the 4709 ingestions of calcium antagonists reported in the most recent two years of the previously mentioned AAPCC data, that the combination of ethanol and nifedipine would have occurred (293). What is different about this case report is the fundamental poison management that was given to the patient. She received syrup of ipecac in order to induce emesis after having ingested a drug which is known to rapidly produce coma, heart block, and hypotension. This act was compounded by the fact that she had already had four episodes of spontaneous emesis, and had been hypotensive and in first-degree AV block for an unspecified amount of time. The use of ipecac in this
Robert S. Hoffman, MD Associate Medical Director Director, Fellowship in Medical Toxicology Department of Health New York City Poison Control Center 455 First Avenue, Room 123 New York, New York 10016
REFERENCES I. Welch BD, Todd K. Nifedipine overdose accompnied by ethanol intoxication in a patient with congenital heart disease. J Emerg Med. 1990;8:169-72. 2. Litovitz TL, Schmitz BF, Matyunas N, Martin TG. 1987 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1988;6:479515. 3. Litovitz TL, Schmitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1989;7:495-545. 4. West LJ, Maxwell DS, Nobel EP, Solomon DH. Alcoholism. Ann Intern Med. 1984;100:405-16. 5. Tenenbein M, Cohen S, Sitar DS. Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Ann Emerg Med. 1987;16:838-41.
nolo1 and clonidine (1). The report for 1988 had not yet been published at the time we submitted our case. They report two cases of nifedipine overdose deaths. One of the cases was nifedipine alone, where the second involved nifedipine, acetaminophen, propoxyphene, and doxepin (2). Possibly even more interesting is that there
IJ Response from Drs. Welch and Todd The data from the American Association of Poison Control Centers reveal three fatalities allegedly from nifedipine. In 1987, one patient succumbed to an overdose of nifedipine but the person had also taken propra-
Guidelines for Letters - Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted. 0736-4679/91 153
$3.00 + .OO
154
The Journal of Emergency
were twenty deaths related to verapamil as opposed to only three deaths from nifedipine (1,2). We certainly believe that alcohol has been used in conjunction with nifedipine and never stated to the contrary (3), however we believe in observation as opposed to assumption. The use of syrup of ipecac in this case is only to be condemned because of the reasons listed in the above letter. We considered whether to include that aspect of the management in our report because we also felt it was not optimal therapy. We did include it because syrup of ipecac is an important issue in overdose management and we feel it necessary to accurately describe pertinent aspects of the case.
0
Radial Head Subluxation
In two recent articles on radial head subluxation, “Nonclassic history in children with radial head subluxation,” Sacchetti et al (1990;8:151-153) and “Radiographic changes with radial head subluxation in children” (1990;8: 265-269), I was extremely surprised by the large number of patients undergoing radiography, both before and after reduction. In Sacchetti’s article, 47% of children received radiographs, despite a classic history of RI-IS. I have been practicing emergency medicine for over 10 years including two years full-time in a pediatric emergency department. I have treated approximately 100 cases of “pulled elbow” and requested pre-reduction x-rays in no more than 10% of those cases. At the children’s hospital, our pediatric radiologists discouraged radiographs for suspect RI-IS and almost always questioned the emergency physician prior to x-raying if the requisition stated “pulled elbow. ” The “classic” history of RHS is readily obtainable in most cases. However, a history of “self-induced” RI-IS must be sought. In this instance, the child has often caught the affected arm between two heavy objects or between a heavy object and a wall, eg, a sofa and a wall. RHS occurs with the child’s attempts to pull the arm free. A similar outcome results during “rough house” play with siblings or friends. The child’s arm becomes trapped beneath the body of a playmate and the child again tries to pull the arm free. History (classic or self-induced) combined with the classic physical presentation (minimally distressed child with the affected arm held in the nursemaid’s position) should be sufficient grounds in all cases to attempt reduction of RHS without pre-reduction radiographs. If reduction is readily accomplished the child should be observed for up to 15 minutes postreduction. If the child begins to use the arm normally, post-reduction radiogrbphs are not neces-
Medicine
Robert D. Welch, MD Keir Todd, PA.C Detroit Receiving Hospital Detroit, Michigan REFERENCES Litovitz TL, Schmitz BF, Matyunas N, Martin TG. 1987 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1988;6:479515. Litovitz TL, Schmitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1989;7:495-545. Welch ED, Todd K. Nifedipine overdose accompanied by ethanol intoxication in a patient with congenital heart disease. J Emerg Med. 1990;8:169-72.
Rather than keeping the child under observation in the emergency unit where resources are limited, it is best to direct the child and parent to a friendly area either within or outside the hospital, eg, playground, coffee shop. The child is more likely to forget his hurt in this setting and begin to use the arm. Even if function has not returned within this time frame, radiographs are not necessary if a palpable “click” has been felt during reduction maneuvers. The child can be discharged for a further period of observation at home, with advice to return if symptoms persist beyond the ensuing two hours. The method of reduction I use most frequently is what I refer to as the “handshake.” I perform this maneuver immediately on patient contact if the nursing history plus the appearance of the affected limb are very suggestive of “pulled elbow.” I briefly introduce myself to the parents, then approach the child to shake his hand by way of introduction. I place one hand around the elbow of the affected arm and with the other take the child’s hand as if to shake it. Concurrently, I quickly pronate the forearm while slightly increasing flexion at the elbow (just beyond 90 degrees). Reduction is readily accomplished in the majority of cases. If nursing history is vague, I endeavor to obtain a “classic” or “self-induced” history before performing the “handshake.” If history remains vague or is unknown, the patient’s appearance is “classic” for RHS, and careful palpation reveals no swelling or bruising and no tenderness/pain response except around the elbow, I will again attempt reduction prior to obtaining radiographs. The only cases which warrant radiographs in my practice are those in which: a) history is suggestive of possible fracture/dislocation; and/or b) examination does not rule out pathology other than RI-IS; and/or sary.
Medicine,
Vol. 9, pp. 153-I 56 1991
Printed in the USA
I-J Nifedipine
* Copyright
0 1991 Pergamon Press plc
situation cannot be recommended both because of the real risk of aspiration, and because of the theoretical risk of exacerbation of the heart block and hypotension caused by the increased vagal tone that accompanies emesis. Knowing that under ideal circumstances only about 38% of drug can be recovered in ipecac-induced emesis (5), we must assess the likelihood of recovering toxin that could not be recovered with four episodes of spontaneous emesis and weigh this potential benefit against the risks of aspiration and exacerbation of heart block.
I read with great concern the case of nifedipine overdose presented by Welch and Todd (1). Although the title implies that both ethanol intoxication and the patient’s underlying congenital heart disease contributed to her morbidity, the authors acknowledge that neither factor appeared to alter either their management, or the subsequent outcome of this case. Furthermore, the authors allege that nifedipine overdose is a rarely reported occurrence. In addition to the three citations given in the text, three fatalities have been reported in the recent national data reports from the American Association of Poison Control Centers (AAPCC) (2,3). Regardless of the frequency of previous citations, one would hope that the publication of this case could add to our collective understanding of nifedipine overdose. It is naive to assume that nifedipine has never been taken in combination with ethanol. It is well accepted that ethanol is a factor in approximately 35% of suicide attempts (4). It would be reasonable to assume that in the 4709 ingestions of calcium antagonists reported in the most recent two years of the previously mentioned AAPCC data, that the combination of ethanol and nifedipine would have occurred (293). What is different about this case report is the fundamental poison management that was given to the patient. She received syrup of ipecac in order to induce emesis after having ingested a drug which is known to rapidly produce coma, heart block, and hypotension. This act was compounded by the fact that she had already had four episodes of spontaneous emesis, and had been hypotensive and in first-degree AV block for an unspecified amount of time. The use of ipecac in this
Robert S. Hoffman, MD Associate Medical Director Director, Fellowship in Medical Toxicology Department of Health New York City Poison Control Center 455 First Avenue, Room 123 New York, New York 10016
REFERENCES I. Welch BD, Todd K. Nifedipine overdose accompnied by ethanol intoxication in a patient with congenital heart disease. J Emerg Med. 1990;8:169-72. 2. Litovitz TL, Schmitz BF, Matyunas N, Martin TG. 1987 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1988;6:479515. 3. Litovitz TL, Schmitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1989;7:495-545. 4. West LJ, Maxwell DS, Nobel EP, Solomon DH. Alcoholism. Ann Intern Med. 1984;100:405-16. 5. Tenenbein M, Cohen S, Sitar DS. Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Ann Emerg Med. 1987;16:838-41.
nolo1 and clonidine (1). The report for 1988 had not yet been published at the time we submitted our case. They report two cases of nifedipine overdose deaths. One of the cases was nifedipine alone, where the second involved nifedipine, acetaminophen, propoxyphene, and doxepin (2). Possibly even more interesting is that there
IJ Response from Drs. Welch and Todd The data from the American Association of Poison Control Centers reveal three fatalities allegedly from nifedipine. In 1987, one patient succumbed to an overdose of nifedipine but the person had also taken propra-
Guidelines for Letters - Letters will appear at the discretion of the editor as space permits and may be subjected to some editing. Three typewritten, double-spaced copies should be submitted. 0736-4679/91 153
$3.00 + .OO
154
The Journal of Emergency
were twenty deaths related to verapamil as opposed to only three deaths from nifedipine (1,2). We certainly believe that alcohol has been used in conjunction with nifedipine and never stated to the contrary (3), however we believe in observation as opposed to assumption. The use of syrup of ipecac in this case is only to be condemned because of the reasons listed in the above letter. We considered whether to include that aspect of the management in our report because we also felt it was not optimal therapy. We did include it because syrup of ipecac is an important issue in overdose management and we feel it necessary to accurately describe pertinent aspects of the case.
0
Radial Head Subluxation
In two recent articles on radial head subluxation, “Nonclassic history in children with radial head subluxation,” Sacchetti et al (1990;8:151-153) and “Radiographic changes with radial head subluxation in children” (1990;8: 265-269), I was extremely surprised by the large number of patients undergoing radiography, both before and after reduction. In Sacchetti’s article, 47% of children received radiographs, despite a classic history of RI-IS. I have been practicing emergency medicine for over 10 years including two years full-time in a pediatric emergency department. I have treated approximately 100 cases of “pulled elbow” and requested pre-reduction x-rays in no more than 10% of those cases. At the children’s hospital, our pediatric radiologists discouraged radiographs for suspect RI-IS and almost always questioned the emergency physician prior to x-raying if the requisition stated “pulled elbow. ” The “classic” history of RHS is readily obtainable in most cases. However, a history of “self-induced” RI-IS must be sought. In this instance, the child has often caught the affected arm between two heavy objects or between a heavy object and a wall, eg, a sofa and a wall. RHS occurs with the child’s attempts to pull the arm free. A similar outcome results during “rough house” play with siblings or friends. The child’s arm becomes trapped beneath the body of a playmate and the child again tries to pull the arm free. History (classic or self-induced) combined with the classic physical presentation (minimally distressed child with the affected arm held in the nursemaid’s position) should be sufficient grounds in all cases to attempt reduction of RHS without pre-reduction radiographs. If reduction is readily accomplished the child should be observed for up to 15 minutes postreduction. If the child begins to use the arm normally, post-reduction radiogrbphs are not neces-
Medicine
Robert D. Welch, MD Keir Todd, PA.C Detroit Receiving Hospital Detroit, Michigan REFERENCES Litovitz TL, Schmitz BF, Matyunas N, Martin TG. 1987 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1988;6:479515. Litovitz TL, Schmitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers national data collection system. Am J Emerg Med. 1989;7:495-545. Welch ED, Todd K. Nifedipine overdose accompanied by ethanol intoxication in a patient with congenital heart disease. J Emerg Med. 1990;8:169-72.
Rather than keeping the child under observation in the emergency unit where resources are limited, it is best to direct the child and parent to a friendly area either within or outside the hospital, eg, playground, coffee shop. The child is more likely to forget his hurt in this setting and begin to use the arm. Even if function has not returned within this time frame, radiographs are not necessary if a palpable “click” has been felt during reduction maneuvers. The child can be discharged for a further period of observation at home, with advice to return if symptoms persist beyond the ensuing two hours. The method of reduction I use most frequently is what I refer to as the “handshake.” I perform this maneuver immediately on patient contact if the nursing history plus the appearance of the affected limb are very suggestive of “pulled elbow.” I briefly introduce myself to the parents, then approach the child to shake his hand by way of introduction. I place one hand around the elbow of the affected arm and with the other take the child’s hand as if to shake it. Concurrently, I quickly pronate the forearm while slightly increasing flexion at the elbow (just beyond 90 degrees). Reduction is readily accomplished in the majority of cases. If nursing history is vague, I endeavor to obtain a “classic” or “self-induced” history before performing the “handshake.” If history remains vague or is unknown, the patient’s appearance is “classic” for RHS, and careful palpation reveals no swelling or bruising and no tenderness/pain response except around the elbow, I will again attempt reduction prior to obtaining radiographs. The only cases which warrant radiographs in my practice are those in which: a) history is suggestive of possible fracture/dislocation; and/or b) examination does not rule out pathology other than RI-IS; and/or sary.