A can’t miss item in the differential diagnosis of neuroleptic malignant syndrome

2 out of 5 stars

Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome. Wilson MP et al. J Emerg Med 2016;51:66-69.

Reference

This review article about neuroleptic malignant syndrome (NMS) is brief but disappointing and misleading on some points. For example, the authors state that:

The majority of cases of NMS develop symptoms within the first week [after starting the offending medication], and virtually all develop symptoms within the first 30 days.

The clinician who takes this statement to the bank could easily miss late-onset NMS occurring as a result of dose change, additional medication, or concurrent illness and dehydration. The clinical scenario the authors present to start the discussion doesn’t even mention the patient’s medications.

On the controversial topic of the role of dantrolene in treating NMS, the paper’s conclusion:

. . .the evidence on the use of dantrolene is contradictory, and all recommend its use.

is gibberish, since “all” doesn’t have a recognizable antecedent The bottom line is that the evidence is indeed contradictory, but many authors recommend use of dantrolene in severe cases since there doesn’t seem to be much downside.

One would hope that a just-published review article would be up-to-date and include important recent information, but the authors do miss a key point. Table 3 lists a differential diagnosis for NMS, but there’s a crucial omission. Anti-NMDA receptor encephalitis can easily be confused with NMS, since it presents with recent-onset psychiatric symptoms that are often treated with neuroleptics. If this diagnosis is not considered it will be missed.

Related posts:

Must-read: Anti-NMDA Receptor Encephalitis

Must-listen podcast: anti-NMDA receptor encephalitis

Rant: ultrasound visualization of pills in the stomach will never make sense

Konstantin Shevtsov/shutterstock.com

Konstantin Shevtsov/shutterstock.com

2 out of 5 stars

Accuracy of Trans-Abdominal Ultrasound in a Simulated Massive Acute Overdose. Sullivan S et al.  Am J Emerg Med 2016 Apr 23 [Epub ahead of print]

Abstract

As soon as emergency portable bedside ultrasound became feasible approximately three decades ago, toxicologists wondered if it would be a useful modality for visualizing pills in the stomach of overdose patients.

The answer, clearly, is no it would not. This misguided paper illustrates why.

This randomized study had a study group (N=10) and a control group (N=10) ingest 50 enteric-coated placebo capsules plus 1 L fluid, or or 1 L fluid only. Ultrasound imaging of the stomach was performed and interpreted by 3 emergency ultrasound-trained sonographers attires 0, 60, and 90 minutes after ingestion. All subjects fasted for at least 6 hours before the study.

Without going into the weeds with precise numbers (consult the abstract if you’re really interested,) we can say that even under these ideal conditions, the sensitivity and specificity of the test were lousy. This is consistent both with the results of a previous pilot study and with common sense. Furthermore, the authors’ premise is ill-considered:

In many cases, traditional ED decontamination therapy with activated charcoal, whole bowel irrigation with polyethylene glycol, and gastric lavage are limited to the first hour post-ingestion. . . .If effective, ultrasound would allow visualization of ingested capsules in the stomach, and could potentially be used to expand the window of decontamination therapy beyond 60 minutes.

NO! As we’ve discussed before, gastric lavage and whole bowel irrigation (WBI) are outmoded, potentially dangerous interventions that should go the way of ipecac and free-range chicken dung as therapeutic options in poisoned patients.(To read our stand on this issue, click here.) The risk is that visualizing something that looks like it may be pills on the ultrasound might motivate the clinician to take unwise measures to go fishing for it. As for charcoal, the concept that a potential benefit might me limited to 1-hour post-ingestion never made any sense. If there are no contraindications (such as altered mental status or an unprotected airway) activated charcoal is relatively safe and easy to administer and is a reasonable option in potentially serious overdoses even hours after the fact.

We should note that, as the authors mention, most overdose patients do not drink 1 L fluid before presentation to improve imaging of the stomach. Also, they usually are not thoughtful enough to be NPO for at least 6 hours. Wo with poor results under ideal conditions, and no rational justification to pursue the topic, do the authors throw in the towel. NO! They conclude:

Further studies that have larger numbers of participants, recruited from actual patient populations, and address the non-fasting status of emergency department patients would be of benefit to make definitive conclusions.

No, it would not be of benefit. This is madness. Please stop. No more studies are needed. This is a blind alley.

Incidentally, in the course of their work the authors made an observation that confirms common sense: ” . . . although it was not a primary endpoint, we did develop a subjective appreciation for how difficult it is to swallow 50 enteric-coated capsules.

Related post:

Use of ultrasound in toxic ingestions: good idea or wild-goose chase?

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5-MAPB: a novel psychoactive benzofuran

5_MAPB

3.5 out of 5 stars

Acute Toxicity Associated With the Recreational Use of the Novel Psychoactive Benzofuran N-methyl-5-(2 aminopropyl)benzofuran. Sofer KE et al. Ann Emerg Med 2016 Apr 26 [Epub ahead of print]

Abstract

5-MAPB is a psychoactive benzofuran with a structure and effects similar to those of MDMA (Ecstasy.) Although there has been scant investigation of its pharmacologic and toxic effects, animal studies indicate that it inhibits re-uptake of monoamines, especially serotonin.

This case report from Zurich Switzerland describes a patient with laboratory-confirmed exposure to 5-MAPB. He presented with signs and symptoms similar to those seen with MDMA or 5-APB: hypertension, tachycardia, diaphoresis, mydriasis, hyperthermia, agitation, hallucinations, seizures, and evidence of myocardial ischemia from coronary vasoconstriction. Treatment included supportive care, external cooling, sedation, and an alpha-blocker (urapidil.) The patient improved markedly within 14 hours of presentation.

Several years ago, a woman in Britain died after ingesting a mixture of 5-APB and 5-MAPB.

One small point: the paper states that the patient’s blood alcohol level was 0.48% (10.6 mmol/L.) This is an error. 0.48 gm% would be 480 mg/dL — six times the legal limit. 10.6 mmol/L is actually 48 mg/dL, which is clearly what the authors intended.

 

Related post:

Benzo Fury: prolonged paranoia and agitation after ingesting 6-APB

Absolute must-read: LA Times on the myth of OxyContin’s 12-hour analgesic effect

A-bottle-of-OxyContin-bra-007

Quick: how long does a dose of Oxycontin provide pain relief?

Most clinicians would probably say 12 hours, since the drug was extensively marketed as a twice-daily opioid analgesic and the manufacturer — Purdue Pharma — cited this originally unique convenience factor as justifying its high cost, which could exceed $630 a bottle.

In an explosive and masterfully written investigative piece by Harriet Ryan, Lisa Girion and Scott Glover,  the Los Angeles Times reported this week that in most patients the duration of the analgesic effect for OxyContin does not last nearly as long as claimed, and that this discrepancy may bear a large part of the blame for the current epidemic of opioid-related overdoses and deaths. The paper makes a number of bombshell allegations:

  • Purdue Pharma has known about this so-called “12-hour problem” from the time the drug began to be marketed, since early clinical trials had indicated that in many patients pain relief lasted only 8 hours or less.
  • Despite this, Purdue aggressively insisted that Oxycontin should only be prescribed for bid (twice daily) dosage to maintain a competitive business advantage.
  • The company and its sales representatives told physicians that if patients complained that pain relief wore off earlier than 12 hours, they should prescribe a higher bid dose rather than increasing the dosing frequency. As a result, many patients ended up on dangerously high doses of Oxycontin, were at increased risk for overdose,  were overly-sedated during much of the day, and still experienced breakthrough pain and withdrawal symptoms when the drug wore off before 12 hours were up.
  • Most importantly, the article cites experts who say that the recurring cycle of pain-relief/euphoria followed by renewed pain and withdrawal symptoms was a set-up for disaster, a scenario that one researcher called a “perfect recipe for addiction.”

The article is full of appalling facts and anecdotes:

  • The ongoing epidemic of opioid overdoses, often seen to have started when OxyContin was approved in 1995, has been associated with almost 200,000 deaths.
  • The doctor who led the Food and Drug Administration’s review of OxyContin, “left the FDA and within two years, was working for Purdue in new product development, according to his sworn testimony in a lawsuit . . .”
  • “Sales reps pitched the drug to family doctors and general practitioners to treat common conditions such as back aches and knee pain. Their hook was the convenience of twice-a-day dosing.”
  • “Company officials worried that if Oxycontin wasn’t seen as a 12-hour drug, insurance companies and hospital would balk at paying hundreds of dollars a bottle.”
  • “In an August 1996 memo headlined “$$$$$$$$$$$$$ It’s Bonus Time in the Neighborhood!” a manager reminded Tennessee reps that raising dosage strength was the key to a big payday.”
  • One Canadian study concluded that patients on higher doses of OxyContin had one chance in 32 of a fatal overdose.

This devastating article is one of the best pieces of medical reporting I’ve every seen. Absolutely, absolutely a must-read.

The Times’ editorial about the article is also well worth reading

To read my Emergency Medicine News column on “The Dark Truth Behind Pain as the Fifth Vital Sign,” click here.

Cardiac effects of loperamide overdose

Loperamide3 out of 5 stars

Not your regular high: cardiac dysrhythmias caused by loperamide. Wightman RS et al. Clin Toxicol 2016 Jun;54:454-458

Abstract

Loperamide is an over-the-counter anti-diarrhea medication that is available without prescription under a variety of brand names including Imodium. In therapeutic doses, loperamide acts as a peripheral mu-opioid receptor agonist but doesn’t cross the blood-brain barrier (BBB). However, in massive overdose loperamide can enter the brain and cause central opioid toxicity, including altered mental status and respiratory.

Although previously loperamide was thought to have little abuse potential, recent reports indicates that it’s increasing being used to produce a recreational “high” or to self-treat opioid withdrawal. It is sometimes called the “poor man’s methadone.”

A little-known manifestation of loperamide toxicity is cardiac dysrhythmias. This case report describes a 48-year-old woman who had ingested up to 40 tablets 2-mg loperamide daily for several weeks to “get a high.” On presentation to hospital she was somnolent and had slurred speech but had stable vital signs. EKG showed markedly increased QRS (164 ms) and QT (582 ms) intervals and no p-waves. After admission to the intensive care unit, she had repeated runs of non-sustained ventricular tachycardia that did not require specific treatment.

A loperamide level was sent and came back at 210 ng/mL (therapeutic ~ 1.2 ng/mL.) The authors state that this is the highest level ever reported in a non-fatal loperamide overdose.

In their discussion, the authors note that loperamide blocks cardiac potassium channels, an effect that would explain the QT prolongation. The authors speculate that QRS widening seen in this case was caused by sodium channel blockade.

Ii would point out that the authors claim that in 2 previously reported cases of loperamide overdose the resulting dysrhythmias were resistant to lipid emulsion rescue therapy. I pulled the relevant papers, and upon review it was not at all clear that neither the data reported by Marraffa et al nor by Enakpene et al were sufficient to support that claim