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The management of propoxyphene poisoning
(Abstracts Peter Rosen, MD
m
editor
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
Frostbite. Holm PCA, Vaggaard L: Plast Reconstr Surg 54:544-551, (Nov) 1974. The most common form of frostbite, superficial - - a white p a t c h of frozen skin - - is usually benign and heals within several days without tissue damage. Nevertheless, frostbite is always serious in the extremities as t h e r e is only a small m a r g i n between superficial and deep frostbite. The frozen part should be rapidly reheated in a b a t h of 100.4-101.2 F (38 C to 44 C). It should not be thawed u n t i l there is no chance of it being refrozen. If general hypotherm i a is present, normal body t e m p e r a t u r e should be re-established first. Hyperbaric oxygen has been found by some to reduce tissue loss, but other investigators have been unable to duplicate these results. The a d m i n i s t r a t i o n of low molecular weight dextran m a y be useful to reduce i n t r a v a s c u l a r sludging. A deep frostbite t h a t has been thawed and refrozen behaves like a deep burn. Treatm e n t should be similar, with early surgical i n t e r v e n t i o n indicated. George Sternbachl MD
The management of propoxyphene poisoning. Lovejoy FH, Mitchell AA, Goldman P: J Pediatr 85:98-100, (July) 1974. Propoxyphene poisoning can cause nausea and vomiting, central nervous system depression, convulsions, respiratory depression a n d cardiovascular collapse. S e r u m levels do not correlate with severity of the poisoning. T r e a t m e n t includes emptying the stomach by gavage or lavage, and adsorption by the use of activated charcoal. Naloxone (Narcan) is the specific antagonist for the depressant effects of propoxyphene, but it m a y require repeated doses. Naloxone may also be the first a g e n t of choice for t r e a t m e n t of convulsions secondary to propoxyphene. (Editor's note: Because of the common use of this drug, it is easy to overlook its potential for lethal effect in overdose.) Donald Blythe, MD
emergency, chemical intoxication, poison; propoxy. phenepoisoning; naloxone.
emergencies, physical agent, thermal, frostbite Severe slowly resolving heroin-induced pulmonary edema. Light RW, Dunham TR: Chest 67:61-64, (Jan) 1975. In heroin-induced pulmonary edema, adequate p02 can only be attained by the use of positive and expiratory pressure (PEEP). Since chemical pneumonitis secondary to aspiration is often a factor, the immediate i n s t i t u t i o n of high dose corticosteroids is advoCated along with adequate volume replacement for hypotension. Recovery is characterized by the gradual clearing of pulmonary infiltrates and a gradual lessening of the severe restrictive ventilatory defects over m a n y weeks. Vincent Markovchick, MD
emergencies, chemical and physical agents; pulmonary edema, heroin-induced; heroin Immunologic dysfunction in heroin addicts. Brown SM, Stimmel B, Taub RN: Arch Intern Med 134:1001-1006, (Dec) 1974. In a study of 38 heroin addicts' immunologic status, multiple abn o r m a l i t i e s were found, including h y p e r g a m m a g l o b u l i n e m i a (IgM a n d . IgG), false-positive t e s t for syphilis a n d positive l a t e x f i x a t i o n test. Studies of l y m p h o c y t e c u l t u r e s s h o w e d decreased in vitro responsiveness to at least one of three mitogens, i l l u s t r a t i n g possible defects in cellular immunity. Contrasted with this grou p was a group of 10 addicts. In most of this group the abnormal studies reverted to normal. While the abnormal results did not correlate with clinical liver disease or biopsy abnormalities, addicts may develop subclinical forms of liver disease. The exact relationship of drug contaminants, previous infections and depressed immunologic status is still speculative.
Richard Ostendorf, MD emergency, chemical intoxication, drugs; addiction, heroin; heroin Page 138 Volume 5 Number 2
Management of skeletal trauma in the patient with head injury. Bellamy, et al: J Trauma 14:1021-1028, (Dec) 1974. The article reviews 142 patients with concommitant head injury and orthopedic problems. Six cases are presented. Points of emphasis are: (1) U l t i m a t e neurologic recovery cannot be predicted on the basis of initial examination. The assumption t h a t full recovery will occur m u s t be made; (2) Anesthesia m a y be delayed two or more hours with open fractures while a neurologic baseline is established; (3) General anesthesia is usually required for surgical procedures in head injury patients. Spinal anesthesia is contraindicated and regional block anesthesia is often unsatisfactory; (4) The best possible reduction of fractures and joint injuries Should be performed during initial care; (5) I n t e r n a l fixation of fractures frequently assists greatly the overall m a n a g e m e n t of airway, skin and p u l m o n a r y function; (6) Fat emboli and alcohol withdrawal in the first few days post-injury m i g h t be confused with intracranial hemorrhage. Differentiation a n d t r e a t m e n t m u s t be carried
out. Joseph Bremmer, MD nervous system emergencies; musculo-skeletal emergencies, head injury Intracerebral hemorrhage and occult sepsis. Yarnell P, Stears J: Neurology 24:870-873, (Sept) 1974. Three cases of clinically silent bacterial endocarditis t h a t presented a s spontaneous intracerebral hemorrhage are reviewed. Two of the patients had evidence of i n t r a v e n o u s drug abuse. Emergency angiography revealed a mycotic a n e u r y s m in relation to the h e m a t o m a in each case t h o u g h all were diagnosed retrospective" ly_ Occult sepsis should be searched for in all cases ofintracerebral
hemorrhage of undefined cause. Richard Feldman, MD infectious emergencies; intracerebral hemorrhage; sepsis, occult; endocarditis, bacterial February 1976 , J ~ F)
m
editor
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
Frostbite. Holm PCA, Vaggaard L: Plast Reconstr Surg 54:544-551, (Nov) 1974. The most common form of frostbite, superficial - - a white p a t c h of frozen skin - - is usually benign and heals within several days without tissue damage. Nevertheless, frostbite is always serious in the extremities as t h e r e is only a small m a r g i n between superficial and deep frostbite. The frozen part should be rapidly reheated in a b a t h of 100.4-101.2 F (38 C to 44 C). It should not be thawed u n t i l there is no chance of it being refrozen. If general hypotherm i a is present, normal body t e m p e r a t u r e should be re-established first. Hyperbaric oxygen has been found by some to reduce tissue loss, but other investigators have been unable to duplicate these results. The a d m i n i s t r a t i o n of low molecular weight dextran m a y be useful to reduce i n t r a v a s c u l a r sludging. A deep frostbite t h a t has been thawed and refrozen behaves like a deep burn. Treatm e n t should be similar, with early surgical i n t e r v e n t i o n indicated. George Sternbachl MD
The management of propoxyphene poisoning. Lovejoy FH, Mitchell AA, Goldman P: J Pediatr 85:98-100, (July) 1974. Propoxyphene poisoning can cause nausea and vomiting, central nervous system depression, convulsions, respiratory depression a n d cardiovascular collapse. S e r u m levels do not correlate with severity of the poisoning. T r e a t m e n t includes emptying the stomach by gavage or lavage, and adsorption by the use of activated charcoal. Naloxone (Narcan) is the specific antagonist for the depressant effects of propoxyphene, but it m a y require repeated doses. Naloxone may also be the first a g e n t of choice for t r e a t m e n t of convulsions secondary to propoxyphene. (Editor's note: Because of the common use of this drug, it is easy to overlook its potential for lethal effect in overdose.) Donald Blythe, MD
emergency, chemical intoxication, poison; propoxy. phenepoisoning; naloxone.
emergencies, physical agent, thermal, frostbite Severe slowly resolving heroin-induced pulmonary edema. Light RW, Dunham TR: Chest 67:61-64, (Jan) 1975. In heroin-induced pulmonary edema, adequate p02 can only be attained by the use of positive and expiratory pressure (PEEP). Since chemical pneumonitis secondary to aspiration is often a factor, the immediate i n s t i t u t i o n of high dose corticosteroids is advoCated along with adequate volume replacement for hypotension. Recovery is characterized by the gradual clearing of pulmonary infiltrates and a gradual lessening of the severe restrictive ventilatory defects over m a n y weeks. Vincent Markovchick, MD
emergencies, chemical and physical agents; pulmonary edema, heroin-induced; heroin Immunologic dysfunction in heroin addicts. Brown SM, Stimmel B, Taub RN: Arch Intern Med 134:1001-1006, (Dec) 1974. In a study of 38 heroin addicts' immunologic status, multiple abn o r m a l i t i e s were found, including h y p e r g a m m a g l o b u l i n e m i a (IgM a n d . IgG), false-positive t e s t for syphilis a n d positive l a t e x f i x a t i o n test. Studies of l y m p h o c y t e c u l t u r e s s h o w e d decreased in vitro responsiveness to at least one of three mitogens, i l l u s t r a t i n g possible defects in cellular immunity. Contrasted with this grou p was a group of 10 addicts. In most of this group the abnormal studies reverted to normal. While the abnormal results did not correlate with clinical liver disease or biopsy abnormalities, addicts may develop subclinical forms of liver disease. The exact relationship of drug contaminants, previous infections and depressed immunologic status is still speculative.
Richard Ostendorf, MD emergency, chemical intoxication, drugs; addiction, heroin; heroin Page 138 Volume 5 Number 2
Management of skeletal trauma in the patient with head injury. Bellamy, et al: J Trauma 14:1021-1028, (Dec) 1974. The article reviews 142 patients with concommitant head injury and orthopedic problems. Six cases are presented. Points of emphasis are: (1) U l t i m a t e neurologic recovery cannot be predicted on the basis of initial examination. The assumption t h a t full recovery will occur m u s t be made; (2) Anesthesia m a y be delayed two or more hours with open fractures while a neurologic baseline is established; (3) General anesthesia is usually required for surgical procedures in head injury patients. Spinal anesthesia is contraindicated and regional block anesthesia is often unsatisfactory; (4) The best possible reduction of fractures and joint injuries Should be performed during initial care; (5) I n t e r n a l fixation of fractures frequently assists greatly the overall m a n a g e m e n t of airway, skin and p u l m o n a r y function; (6) Fat emboli and alcohol withdrawal in the first few days post-injury m i g h t be confused with intracranial hemorrhage. Differentiation a n d t r e a t m e n t m u s t be carried
out. Joseph Bremmer, MD nervous system emergencies; musculo-skeletal emergencies, head injury Intracerebral hemorrhage and occult sepsis. Yarnell P, Stears J: Neurology 24:870-873, (Sept) 1974. Three cases of clinically silent bacterial endocarditis t h a t presented a s spontaneous intracerebral hemorrhage are reviewed. Two of the patients had evidence of i n t r a v e n o u s drug abuse. Emergency angiography revealed a mycotic a n e u r y s m in relation to the h e m a t o m a in each case t h o u g h all were diagnosed retrospective" ly_ Occult sepsis should be searched for in all cases ofintracerebral
hemorrhage of undefined cause. Richard Feldman, MD infectious emergencies; intracerebral hemorrhage; sepsis, occult; endocarditis, bacterial February 1976 , J ~ F)