Under Pressure
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Detailed Examination in Suspected Opioid Overdose

In cases of suspected opioid overdose, following stabilization, the treating clinician should inquire about the use of all opioid analgesics, Acetaminophen (including products co-formulated with the drug), and illicit substances, and also determine whether the patient has had contact with anyone receiving pharmacologic treatment for chronic pain or opioid dependence. In performing the physical examination, the physician should evaluate the size and reactivity of the pupils and degree of respiratory effort, and look for auscultatory findings suggestive of pulmonary edema. The patient should be completely undressed to allow for a thorough search for fentanyl patches; In addition, the clinician should palpate muscle groups; the firmness, swelling, and tenderness that characterize the compartment syndrome (which results when comatose patients lie on a muscle compartment for a long time) warrant direct measurement of compartment pressures. Finally, the Acetaminophen concentration should be measured in all patients because of the prevalence of diversion, and misuse of Acetaminophen-containing opioids. Clinicians often overlook Acetaminophen hepatotoxicity. Note that qualitative analyses of urine for drugs of abuse (toxicology screens) rarely affect decisions about patient care and have little role in the immediate evaluation and management of opioid intoxication.

Diagnosing and Treating Suspected Opioid Overdose

Opioid analgesic overdose encompasses a range of clinical findings; these range from the classical toxidrome of apnea, stupor, and miosis, to respiratory depression alone. At the bedside, the most easily recognized abnormality is a decline in the respiratory rate (RR), potentially culminating in apnea. Note in particular that a RR of 12 cycles per minute or less in a patient who is not in physiologic sleep strongly suggests acute opioid intoxication, particularly when accompanied by miosis or stupor. It should be appreciated that the absence of miosis does not exclude opioid intoxication; normally reactive or mydriatic pupils can occur in poisoning secondary to meperidine, propoxyphene, and tramadol, and following polysubstance ingestions. Conversely, overdose from antipsychotic drugs, anticonvulsant agents, ethanol, and other sedative hypnotic agents can cause miosis and coma, but the respiratory depression that defines opioid toxicity is usually absent. The management of opioid overdose, regardless of the causative agent, varies little. Naloxone, the antidote of choice, is a competitive mu opioid-receptor antagonist which reverses all signs of intoxication. It is active via the parenteral, intranasal, or pulmonary routes of administration. Note that the dosage of Naloxone is determined empirically. The initial dose for adults is 0.04 mg; if there is no response, this should be increased every 2 minutes, to a maximum of 15 mg.

Drugs that can cause Hypotension

A number of drugs can cause low blood pressure, including: - Diuretics, such as Furosemide and Hydrochlorothiazide - Alpha blockers, such as Prazosin - ACE inhibitors, such as Lisinopril - Beta blockers, such as Atenolol, Propranolol and Timolol - Opioids, such as Morphine - Anti-Parkinson drugs, such as Pramipexole, or those containing Levodopa - Tricyclic Antidepressants, including Doxepin, Imipramine, Protriptyline and Trimipramine - Sildenafil or Tadalafil, particularly in combination with medication containing Nitroglycerin

Evaluation of a Hypotensive Patient

Hypotension is not a disease per se, but rather a sign of an underlying pathological process; it can occur secondary to both acute disease, as well as chronic conditions. The emergency physician must determine what is present, and tailor the aggressiveness of interventions based on the underlying etiology. In most acute cases, the approach is usually unstructured, with a focus on stabilising the vitals while investigating the cause. Because the differential diagnosis is so broad, most guidelines are diagnosis specific and do not provide a systematic approach to managing hypotension in general. Fluid resuscitation, typically with an isotonic crystalloid solution (e.g. normal saline or Ringer's lactate) remains the mainstay of the initial treatment of these patients. Exceptions to this rule include patients with cardiac decompensation (such as in left heart failure). Where the above fails to correct hypotension, pressors become a consideration. Current critical care and sepsis treatment guidelines recommend the use of Norepinephrine or Dopamine as first line vasopressor agents. Dobutamine may be added if cardiac support is necessary.

Lisinopril Overdose

Over the last decade, angiotensin converting enzyme (ACE) inhibitors have assumed an increasingly prominent role in the treatment of hypertension and chronic heart failure, and in the reduction of cardiovascular risk. The number of different ACE inhibitors has also expanded, and their overall accessibility has increased. An ACE‐inhibitor overdose may cause severe hypotension; this has been reported after ingestion of Captopril, Enalapril, Lisinopril and Quinapril. Hypotension may be prolonged or fatal in severe cases. Patients with moderate to severe hypotension require close observation in a critical care environment, administration of intravenous fluids and inotropic support. Administration of intravenous angiotensin II may restore blood pressure where hypotension is refractory to other pressor agents, and Naloxone and Aminophylline have been effective in certain situations. Despite the potential to cause severe hypotension, the hemodynamic effects after an ACE‐inhibitor overdose are generally mild, and most patients do not require any specific treatment

Psychiatric Consultation in the ER

Evaluation of the mental health of patients with serious medical illness, formulation of their problems and diagnosis, and organization and implementation of an effective treatment plan involves complex clinical skills that require specialized training. In addition to the usual psychiatric examination, specialized knowledge about diagnosis, medicolegal issues, and psychotherapeutic and psychopharmacological interventions is necessary. In an ideal setting, there should be adequate staffing to provide psychiatric consultation 24 hours per day, throughout the year. Unfortunately though, available services vary substantially from institution to institution. In some large academic medical centers, the consultation service is comprised of a team of psychiatrists, psychologists, residents, fellows, nurses, social workers, and medical students. In others, the consultation service is staffed only by an attending psychiatrist, a psychologist, or a chaplain. Consultations are usually requested by physicians who are directly responsible for the care of the patient. Subsequently, the psychiatric specialist sees the patient. It should be appreciated that timing is a crucial variable for the effectiveness of psychiatric intervention. Early detection strategies for high-risk patients are very important for better care. Depending on the clinical setting, the psychiatrist may manage the case themselves, or delegate it to another mental health professional (under their supervision). After the initial consultation, a follow-up examination is conducted, and ongoing management is reviewed. Disposition planning follows. Some patients are determined to have no psychiatric disorders, while other patients require treatment in medical/surgical units, or in an inpatient psychiatric unit; yet others will benefit from outpatient psychiatric care.

Suicide Screening in the Emergency Department

Emergency departments (EDs) are increasingly recognized as an important component of suicide prevention. Studies indicate that an average of 412,000 ED visits per year in the USA are related to intentional self-harm or suicide attempts. Furthermore, although suicides are difficult to predict in the general population, ED patients presenting with risk factors such as substance abuse, or psychiatric disorders such as depression are a readily identifiable population at elevated risk for suicidal behavior. In addition, persons who present to EDs for non-mental health reasons have higher proportions of occult or silent suicide ideation. Despite this, many ED staff do not routinely screen for suicidal ideation or behavior; currently, the type and degree of screening is more based on provider and service characteristics rather than on patient characteristics.

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