Surely the NEJM could do a better review of delirium tremens

delirium_tremens_label_22.5 out of 5 stars

Recognition and Management of Withdrawal Delirium (Delirium Tremens). Schuckit MA. N Engl J Med 2014 Nov 27;371:2109-2113.

No abstract available

This is an amazingly inept paper, even by the traditionally low standards of the New England Journal‘s  “Review Article” section. It was written by a psychiatrist who — on the basis of this piece — seems not to deal with severe alcohol withdrawal or delirium tremens at all.

At times, the author does not appear to appreciate the serious nature of DTs and the difficulty of treating the condition adequately. For instance, he states that “treatment is best carried out in a locked inpatient ward or an ICU.” I would suggest that the thought of managing a patient with  DTs in a locked (presumably psychiatric) ward is — to use the technical term — nuts.

But Dr. Schuckit is not done. Later on he writes:

“The doses needed to control agitation and insomnia vary dramatically among patients and can be prodigious (e.g., >2000 mg of diazepam in the first 2 days in some patients); this underscores the advisability of providing treatment in a hospital, preferably in an ICU.”

Excuse me? It is only “advisable” to treat DTs in the hospital? I’d say it’s damned mandatory. It is just beyond me why the author does not say simply: “Patients should be treated in the ICU.” Full stop.

Although the author does say that the patient should be worked-up for co-morbid and contributing conditions, he gives little guidance on how to go about this evaluation. He does not mention the importance of ruling-out hypoglycemia, trauma, infection or specific electrolyte abnormalities. Although he recommends administering thiamine to patients with suspected Wernicke’s encelphalopathy, he does not describe the findings that would lead to such suspicion.

There is some useful information in the article about the time course of alcohol withdrawal and DTs, the revised CIWA Assessment Scale, and various treatment regimens. I appreciate that he stressed the importance of administering (if required) hefty doses of benzodiazepines, and gave short shrift to newer adjunctive agents such as dexmedetomidine.

It is a shame that the article appears to have received no input from a medical toxicology, emergency practitioner, or critical care specialist, who could have brought up crucial issues that the article blithely ignores. in the end, the author concludes:

Data on the most effective care for patients with withdrawal delirium are lacking. Since the low potential of profit from this research may undercut interest from pharmaceutical companies, treatment trials sponsored by the National Institutes of Health are warranted.”

Good luck with that one.
Related posts:

CPC: alcohol withdrawal with delirium tremens and a significant missed diagnosis

More criticism of New England Journal CPC on Alcohol Withdrawal

Patient complains of bugs on her skin — could it be tox?

2.5 out of 5 stars

Case 37-2014: A 35-Year-Old woman with Suspected Mite Infestation. Beach SR et al. N Engl J Med 2014 Nov 27;371:2115-2123.

No abstract available

This case — part of the Journal‘s “Case Records of the Massachusetts General Hospital” series — describes a 35-year-old woman had presented to the emergency department complaining of a parasitic skin infection:

“During the 10 days before this presentation, she reported seeing white ‘granular balls,’ which she thought were mites or larvae, emerging from and crawling on her skin, sheets, and clothing and in her feces, apartment, and car, as well as having an associated pruritic rash.”

She was referred to dermatology, but before the appointment was seen at another hospital, diagnosed with possible cheyletiellosis, and treated with selenium sulfide shampoo.

The patient had a complicated medical and psychiatric history, including hepatitis C virus infection and drug dependency (opiates, amphetamine, benzodiazepines.) Three days before presenting to the third hospital (presumably Mass General), she had run out of clonazepam. On examination, her pulse rate was 100/min and her blood pressure 141/95 mm Hg. There were excoriations over most of her body excepting the mid-back. Her urine drug screen was positive for amphetamines. She was admitted to the psychiatry service with a diagnosis of delusional parasitosis.

Since this is a medical toxicology blog, it’s not really a spoiler to reveal that the final diagnosis was drug-related. The obvious candidates were amphetamine effects and benzodiazepine withdrawal. Since symptoms started before clonazepam was discontinued, the final diagnosis was: “Amphetamine-induced psychosis, with delusional parasitosis and neurotic excoriations.” During the presentation, the discussant notes that drug-related causes of delusional parasitotis include:

  • opiate withdrawal
  • benzodiazepine withdrawal
  • amphetamines
  • cocaine
  • synthetic cannabinoids
  • synthetic cathinones (“bath salts”)
  • hallucinogens

The discussion itself is rather tedious (at least to a medical toxicologist) as it goes at length through the dermatologic and psychiatric conditions on the differential diagnosis of delusional parasitosis.

Those interested in formication (I hope spell-check doesn’t “correct” this term!) will want to read a short post about the subject at the Psychology Today website.

Tox on the Web: deadly cocaine/fentanyl combination, the rising price of naloxone, and more


Cocaine/Fentanyl Kills 3 in North Carolina: WTVD-ABC Eyewitness News in Raleigh, North Carolina reports that 3 people local Chatham County died over the weekend — and another 6 were taken to hospital — after using cocaine that had been surreptitiously adulterated with fentanyl. This is somewhat unusual, although many deaths in the past have been caused by fentanyl-laced heroin. A similar death occurred recently in Upstate New York.

Naloxone Sticker Shock: The New York Times reported that with demand for intranasal naloxone increasing exponentially as take-home programs and use by police departments and other first-responders become more accepted, the price of the antidote has increased by 50% or more.

Podcast of the Week: Free Emergency Medicine Talks has just posted a lively lecture by Bob Hoffman about “Controversies in Emergency Medicine.” Nothing if not opinionated, Dr. Hoffman has interesting things to say about thiamine and Wernicke’s encephalopathy, gastric decontamination, hyperbaric oxygen therapy, and several other topics. At one point Dr. Hoffman takes on TPR‘s position that gastric lavage has known risks and no clear benefits, and should no longer be advocated. I won’t go into detail about all the points of his argument with which I disagree, but will point out the sly way in which at 15:20 he tries to advance the notion that adverse effects caused by lavage are not really complications, but bad technique, and “bad technique is not a complication of the procedure but it’s a complication of the operator and it may be bad luck.” The lecture is worth a listen, and can be accessed by clicking here. [HT @EMSwami]

Saturday SMACCdown: Should Real Airway Docs Use a Checklist?

In this verbal cage match from the 2014 SMACC Gold conference, Dr. Tim Leeuwenburg (@KangarooBeach) goes up against Dr. Minh Le Cong (@ketaminh) to debate the question: “Should real airway docs use checklists?” Very entertaining, and both sides make good points.

Remember, SMACC Chicago takes place June 23-26, 2015. Many of the pre-conference workshops have already sold out, and registration for the conference itself has been brisk even at this early date. You can view the program and the amazing list of speakers lined up at the SMACC Chicago website. This is really the one conference in 2015 you won’t want to miss!


Related posts:

Saturday with SMACC: Weingart on sepsis in New York City

Saturday with SMACC: Motorbike Mayhem

Saturday with SMACC: Evidence-Based Education — What Works

Saturday with SMACC: The Art and Science of Fluid Responsiveness

Saturday with SMACC: Resuscitation Dogmalysis

Saturday with SMACC: 17 Minutes

Palytoxin: deadlier than fugu?



3 out of 5 stars

Hyperkalemia, Hyperphosphatemia, Acute Kidney Injury, and Fatal Dysrhythmias After Consumption of Palytoxin-Contaminated Goldspot Herring. Wu M: et al. Ann Emerg Med 2014 Dec;64:633-6.


Palytoxin, a huge heat-stable molecule, is one of the most deadly of all the marine toxins. Fortunately, cases of severe palytoxin poisoning are relatively rare. This paper from Taiwan describes 4 patients from a single family who became symptomatic after eating fish soup made from the local catch. One person died. The presence of palytoxin was confirmed in samples of leftover fish.

The following questions are based on point made in the paper. Click on the question to reveal the answer:

Palytoxin poisons the membrane sodium-potassium pump, impairing the ability of cells to maintain electrical gradients. Essentially, it turns the normally carefully regulated pump into an open non-specific cation channel. Sodium ions rush into the cell — creating a permanent state of depolarization —  along with calcium ions that ultimately cause cell death. Calcium also mediates release of neurotransmitters, histamine, and catecholamines.

Palytoxin is a potent vasoconstrictor, especially affecting heart and kidney vessels.

    • Goldspot herring (Herklotsichthys quadrimaculatus)
    • boxfish
    • filefish
    • trigger fish
    • cowfish
    • parrotfish
    • freshwater puffer fish
    • Sea anemones
    • Crabs
    • mackerel
    • Anchovies
    • Sardines

Palytoxin itself is probably produced by dinoflagellates such as Ostreopsis Fish and other marine creatures acquire the toxin by eating plankton.

  • Neurological: dizziness, perioral and limb paresthesias, weakness.
  • Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain
  • Cardiovascular: hypertension, bradycardia, dysrhythmias
  • Renal: acute renal failure (from rhabdomyolysis), anuria
  • Other: myalgia, muscle spasm, respiratory distress,arthralgia, acute hyperkalemia, acute hyperphosphatemia

Many marine envenomations can present in a similar manner, including tetrodotoxin poisoning, neurotoxic shellfish poisoning, paralytic shellfish poisoning (saxitoxin). The major alternative diagnosis is usually ciguatera.

Supportive care with aggressive hydration to maintain urine output.

Goldspot herring (Herklotsichthys quadrimaculatus)

Goldspot herring (Herklotsichthys quadrimaculatus)


Best paper yet on screening suspected body packers

Body packer

Body packer

4.5 out of 5 stars

Body packing: a review of general background, clinical and imaging aspects. Bert FH et al. Radiol Med 2014 Oct 10 [Epub ahead of print]


I’d say this is the best article on imaging suspected body packers we’re likely to see, but with the rapid evolution of radiological technology it will likely need to be updated every year or so. Nevertheless, it is the best review of the topic available, and has spectacular illustrations.

The five authors rely on their experience as radiologists in major European cities, as well as published medical  literature, to review test characteristics of various imaging modalities in detecting body packers as well as body pushers (smugglers who insert large drug packets into the rectum or vagina in an attempt to transport them surreptitiously.) The drug packets usually contain cocaine or heroin.

Some key points made in the paper:

  • Plain abdominal x-rays are relatively insensitive in detecting ingested drug packets, especially when fewer than a dozen are present (sensitivity 40-90% in various studies.)
  • Oral contrast does not increase sensitivity of the plain abdominal film.
  • Computed tomography is highly sensitive in detecting the presence of ingested drug packets (95 – 100%.)
  • Most current screening protocols published in the medical literature call for an abdominal and pelvic CT scan without oral or intravenous contrast.
  • As technology improves,  CT scanning is able to provide reliable screening information using radiation doses that are reduced an order of magnitude compared to those previously required.
  • The use of MRI for screening suspected drug packers or pushers is not yet ready for prime time.

This paper has many interesting x-ray, CT, and ultrasound images, as well as 30 references — some as recent as this year. Highly recommended.
Related posts:

Conservative treatment of asymptomatic body packers?

Body packers: can CT determine the number of drug packets?

MRI for body packers?

Low-dose abdominal CT is superior to plain film for imaging suspected body packers

Cannabis body packers

Treatment protocol for symptomatic body packers (mules)

Cocaine mules: what to do with body packers
[Note: photograph of body packer is not from the paper discussed in this post]