Faculty Bibliography

Whole bowel irrigation with polyethylene glycol electrolyte lavage solution has been recommended as an adjunct to traditional overdose management. Although combined activated charcoal and whole bowel irrigation could enhance the efficacy of both modalities, this improvement remains largely speculative. An in vitro experiment was designed to determine whether polyethylene glycol electrolyte lavage solution alters the adsorption of theophylline to activated charcoal. Theophylline was agitated with activated charcoal in either water or polyethylene glycol electrolyte lavage solution, at each of three activated charcoal:theophylline ratios; 1:1, 3:1, and 10:1. The concentration in the supernatant was determined by high pressure liquid chromatography, and the maximal adsorptive capacity of activated charcoal for theophylline was calculated from the Langmuir equation. The percent of theophylline adsorbed by activated charcoal in water was 16 +/- 4%, 67 +/- 5%, and 97 +/- 3% for the 1:1, 3:1, and 10:1 ratios, respectively. This was decreased to 17 +/- 5%, 37 +/- 3%, and 62 +/- 2% when polyethylene glycol electrolyte lavage solution was added. A statistical difference (p less than 0.05) occurred at the 3:1 and 10:1 activated charcoal:theophylline ratios. Similarly the maximal adsorptive capacity was decreased 23% from 264 mg/g to 203 mg/g when polyethylene glycol electrolyte lavage solution was added to activated charcoal prior to theophylline. Polyethylene glycol electrolyte lavage solution significantly decreases adsorption of theophylline to activated charcoal in vitro. In vivo studies are required to confirm these findings. If activated charcoal is to be used clinically for theophylline toxicity, the authors suggest the possibility of larger quantities of activated charcoal, and administering activated charcoal in a slurry of water before the initiation of whole bowel irrigation

The patient who presents with an agitated delirium, poses a clinical dilemma in the critical care setting. The aetiologies for this presentation are numerous and includes cocaine intoxication. Life threatening complications from the agitation can be effectively limited when the patient is adequately sedated with benzodiazepines and hyperpyrexia is controlled. This strategy is nonspecific for many of the aetiologies, of greatest therapeutic benefit for patients with sedative-hypnotic withdrawal and cocaine intoxication, and places no patient at increased risk

The intravenous infusion of calcium 2-amino ethanol phosphate was coincidental with cardiopulmonary arrest in a 53-year-old woman with a history of multiple sclerosis. Resuscitation was followed by massive hemolysis, renal failure, adult respiratory distress syndrome, shock liver, and disseminated intravascular coagulation. This agent, in use by at least one practitioner in West Germany for the treatment of inflammatory and autoimmune disorders is not FDA approved for use in the United States, nor is clinical investigation underway. It is currently thought to be in use by about 200 practitioners throughout this country as treatment for multiple sclerosis. It is apparently obtained in West Germany and brought illegally into the United States. This is the first known report of an adverse drug reaction associated with the use of this product

Gastrointestinal drug smuggling is a common problem in many major cities. Though the majority of cases never require medical attention, the 'body-packer' frequently presents with life-threatening symptoms of intoxication, including seizures and cardiorespiratory collapse, as well as mechanical obstruction from the ingested drug packets. The risk to asymptomatic smugglers may vary with packaging materials, and remains unknown. Lack of controlled studies, and variations in packaging materials and clinical outcomes have prevented formulation of a consistent management strategy. Current recommendations for asymptomatic body-packers vary from immediate surgical removal, to use of laxatives, to observation. The authors present the first reported case of an asymptomatic cocaine body-packer treated with whole bowel irrigation with polyethylene glycol electrolyte lavage solution. This strategy was safe, well tolerated, resulted in the rapid elimination of drug packets from the gastrointestinal tract, and facilitated assessment by contrast radiography. The potential benefits and limitations for the use of whole bowel irrigation in this difficult problem are discussed

As long as drug use and abuse persist in our society, a significant number of patients with various types of drug withdrawal will present to Emergency Departments. It is imperative that we recognize the signs and symptoms of drug withdrawal and render the appropriate treatments. Although it may be easy to recognize 'skid row' alcoholics, a drug abuser with track marks on his (or her) arms or with a perforated nasal septum, the executive alcoholic, the elderly patient on chronic diazepam therapy, or the 'blue collar' worker using cocaine may be more common and more elusive. Because most drug abusers use and can be dependent on multiple drugs, detoxification may need to proceed with one drug or one class of drugs at a time. Although our discussion has concentrated on the acute presentation and treatment of these symptoms for the emergency physician, we recognize that the acute treatment of withdrawal symptoms is only a small but vital part of withdrawal treatment. These patients will require chronic treatment, including social and psychologic counseling. As emergency physicians, by performing our jobs of recognition, stabilization, and counseling, we will fulfill the first critical link in the treatment of these patients