Predicting delirium tremens in patients with alcohol withdrawal seizures

delirium_tremens_label_22 out of 5 stars

Clinical predictors for delirium tremens in patients with alcohol withdrawal seizures. Kim DW et al. Am J Emerg Med 2015 Feb 23 [Epub ahead of print]


Being able to predict which patients with alcohol withdrawal seizures will go on to develop delirium tremens (DTs) may lead to improved clinical outcomes and decreased morbidity and mortality.  The goal of this retrospective Korean study was to identify clinical and laboratory findings in emergency department (ED) patients with seizures attributed to alcohol withdrawal and would predict progression to delirium tremens.

ED patients presenting to 4 tertiary referral centers with seizures over a 22 month period were identified retrospectively. Patients with seizure etiology other than alcohol withdrawal were excluded. Eligible patients were observed for a minimum of 48 hours. Diagnosis of DTs was made according to the definition in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV.)

The authors identified 97 eligible patients with alcohol withdrawal seizures. Thirty-four (35%) of these went on to be diagnosed with delirium tremens. High blood homocysteine levels and low platelet count were independent risk factors for progression to delirium tremens.

Unfortunately, these results will, in my opinion, turn out to be less than clinically useful. For one thing, homocysteine levels are not readily available at most institutions, and are unlikely to be so in the foreseeable future. Secondly, making multiple comparisons (the authors analyze 24 clinical and laboratory factors) means that some apparent distinguishing characteristics will just appear by chance. Finally, even given these limitations, the factors the authors identify are that good, despite using cutoffs that were not predetermined. A platelet count of 137,000/μL was only 73% sensitive, and a homocysteine level of 14.5 micromoles per liter was only 81% sensitive. These population numbers are not good enough to be helpful in the individual patient.
Related posts:

Surely the NEJM could do a better review of delirium tremens

Risk of completed suicide after initial hospitalization for deliberate overdose

3.5 out of 5 stars

Risk of Suicide Following Deliberate Self-poisoning. Finkelstein Y et al. JAMA Psychiatry 2015 Apr 1 [Epub ahead of print]


The authors primary objective was to determine the risk of subsequent successful suicide in patients discharged from hospital after a first suicide attempt. They used multiple healthcare databases to identify patients hospitalized for first suicide attempt in Ontario, Canada from April 2002 through December 2010. Subjects identified were followed through the end of 2011. For each subject a control patient without history of self-poisoningt was selected, matched for age, gender, and calendar year.

The search identified 65,784 patients discharged from hospital or the emergency department after a first suicide attempt. These patients were followed for a median of 5.3 years. Of these, 976 committed suicide and were over 40 times more likely to do so than controls. Overdose was the method in 41% of subjects who ultimately killed themselves. The median time from initial self-poisoning to completed suicide was 585 days.

Given the immensity of the problem, the (relatively) small percentage of patients who went on to kill themselves during the follow-up period, and the length of time from first attempt to completed suicide, I have my doubts that much can done to approach this problem as a public health issue. However, these results lead to some important considerations for medical toxicologists, emergency medicine practitioners, and psychiatrists. I sometimes find it astounding how often patients who have attempted self-harm with their own particularly dangerous psychiatric medication — drugs such as tricyclics, venlafaxine, and bupropion — are discharged from hospital on that same medication.  Certainly any patient who presents with a suicide attempt should have a thorough re-evaluation of his or her drug regimen by a psychiatrist and psychiatric pharmacologist to determine which medications are dangerous, which are essential, and which could be replaced by less risky alternatives.


Less is more: fatal C. difficile colitis after empiric antibiotics

Aspiration pneumonitis

Aspiration pneumonitis

4 out of 5 stars

Antibiotics “Just-In-Case” in a Patient With Aspiration Pneumonitis. Joundi RA et al. JAMA Intern Med 2015 Apr 1;175:489-490


This very brief but very important case report contains more key points than most papers 10 times as long. The case describes a 50-year-old man with cerebral palsy and a known seizure disorder who had several witnessed tonic-clonic seizure episodes treated with a benzodiazepine. Subsequent chest x-ray revealed multiple bibasilar opacities consistent with aspiration.

The patient was started on piperacillin-tazobactam. Although he showed significant clinical improvement on the second hospital day, the antibiotics were continued for a full 7-day course because of the “possibility” of aspiration pneumonia.

The patient was discharged in good condition after 10 days in hospital, but returned a week later with diarrhea, shock, and an increased white blood cell count. Work-up revealed Clostridium difficile colitis. Despite medical treatment, he succumbed to the infection on hospital day 18.

In their cogent discussion, the authors point out the differences between aspiration pneumonitis and aspiration pneumonia:

Aspiration pneumonitis is an acute chemical caustic lung injury that begins abruptly — often after a witnessed seizure — and generally improves within 48 hours. Treatment generally consists of supportive care without antibiotics. In approximately 1 in 4 of these patients bacterial infection will supervene and be manifest by clinical worsening 2 – 7 days after the episode of aspiration. Empiric prophylactic antibiotics have not been shown to provide benefit in routine cases, may select for resistant organisms, and subject the patient to risk of an adverse event, such as in this case.

Aspiration pneumonia is a bacterial lung infection in which symptoms begin gradually, often without a witnessed episode of aspiration.

The authors conclude:

Because patients with aspiration pneumonitis are often critically ill, withholding antimicrobial therapy can be challenging. In those with witnessed aspiration events, there should be the necessary confidence to forego antibiotic therapy for the first 48 hours while continuing supportive management. Lack of expected improvement within 48 hours or recurrence of fever and worsening respiratory status 2 or more days following the aspiration event suggests the development of pneumonia that warrants initiation of antimicrobial therapy.

Possible exceptions to this approach include patients with conditions that predispose to bacterial colonization of gastric contents. These include patients with small bowel obstruction, gastroparesis, and those who use antacids, H2-blockers, or proton-pump inhibitors. In these cases, early antibiotic treatment may be justified.

As the White Rabbit said, “Don’t just do something, stand there!“:


[Chest x-ray showing aspiration pneumonitis used under Creative Commons license]

Factors associated with emergency department opioid-related adverse drug events

hydromorphone3.5 out of 5 stars

Preventing Iatrogenic Overdose: A Review of In-Emergency Department Opioid-Related Adverse Drug Events and Medication Errors. Beaudoin FL et al. Ann Emerg Med 2014 Apr;65:423-431.


The authors retrospectively reviewed records of patients from 2 academic urban hospitals who were treated with naloxone after receiving an opioid in the emergency department (ED). Their goal was to identify factors associated with opioid-related adverse drug events and develop strategies that might minimize the incidence of such events.

Using good methods for retrospective chart reviews, the authors identified 73 patients over approximately a 3-year period with opioid-related adverse events in the ED; in 43 of these patients, the adverse event caused harm (for example, hypoxia, need for hospital admission or ventilatory assist, death).

The following were some of the factors associated with opioid-related medication errors and adverse events:

  • altered mental status
  • renal impairment
  • hepatic impairment
  • sleep apnea
  • baseline hypercarbia
  • concomitant administration of other sedatives (such as benzodiazepines)
  • opioids administered by multiple routes

Hydromorphone (Dilaudid) was the opioid most involved in cases with adverse events. It is not clear from the data whether this is because it was the drug most frequently administered, or because it is uniquely risky. The authors suggest that since hydromorphone is a high-potency medication whose therapeutic dose is relatively low, some practitioners might underestimate its strength. Certainly, any physician administering hydromorphone should be familiar with its pharmacology and toxicology.

This study has a number of limitations, which the authors discuss candidly. For example, the study design would miss capturing a patient who received an opioid in the emergency department, was admitted, and died from respiratory depression on the floor. Nevertheless, this is a valuable reminder of the patient, provider, and systems factors that should raise red flags of caution when administering opioids in the emergency department. Worth reading.


“Flakka”: one of the most bizarre drugs yet

South Florida has recently seen a number of cases associated (at least by history) by exposure to a street drug called “Flakka”:

In Lake Worth, a naked man brandishing a handgun stood on the roof of an apartment building, shouting “I feel delusional, and I’m hallucinating.”

In Fort Lauderdale, a man tried to kick in the door of the local police station because he thought he was being chased by automobile seeking to do him harm.

And 2 weeks ago, also in Fort Lauderdale, a man impaled himself on a spiked fence around a police station apparently in thrall to a paranoid delusion:

It is no wonder that “flakka” is also called “$5 insanity.” Although I am not aware of reports specifically analyzing samples of the drug, it appears that it frequently contains the synthetic cathinone alpha-PVP, which has appeared in other parts of the country where it is called “gravel.”

As always, it is important to note that anyone who uses a drug called “flakka” (or “Molly” or “Gravel” or . . . .) has no real idea of what it contains, or in what dose.

To read my Emergency Medicine News column on alpha-PVP, click here.

To read Time magazines coverage of this story, click here.

Related posts:

Death after injecting alpha-PVP

The science of alpha-PVP, a second-generation bath salt

Do we know the best treatment for jellyfish stings?

2.5 out of 5 stars

What is the Most Effective Treatment for Relieving the Pain of a Jellyfish Sting? Ostermayer DG, Koyfman A.  Ann Emerg Med 2015 Apr;65:432-433.


This short article manages to pack a maximum amount of confusion into a very small space. The authors perform a literature search to find evidence that would answer their title question, but come up with only a single relevant randomized controlled trial that included exclusively stings from a specific jellyfish, the bluebottle (Physalia).

That study involved 96 subjects with apparent bluebottle stings, and compared immersion of the affected body part in 45oC  water with application of ice packs. In that paper, hot water immersion was clearly superior. According to the International Life Saving Federation, the common belief that application of vinegar will improve outcomes applies only to stings by box jellyfish. (Vinegar will not decrease pain, but only deactivate nematocysts that have not yet fired and halt profession of symptoms.) Pace the “Friends” episode excerpted above, there have been no double-blind randomized controlled trials of peeing on jellyfish stings of any type.

Related posts:

Jellyfish conquering the world

 Is magnesium beneficial in treating Irukandji jellyfish stings?

Jellyfish sting: evidence does not support peeing on it

Evolution of a jellyfish sting

Is that a jellyfish on your leg or are you just glad to see me? Priapism and Irukandji Syndrome

Irukandji syndrome: a superb review article