Faculty Bibliography

Objective: Aggressive gastric emptying is often withheld in poisoning due to concerns over safety and efficacy. Despite this, endoscopy performed by emergency medicine physicians demonstrates significant retention of residual drug products many hours after ingestion [1]. Decedents may also demonstrate significant drug retention [2]. We developed a novel video technique in an attempt to improve the safety, efficacy, and completeness of orogastric lavage.
Method(s): Using SolidWorksTM (Dassault Systems, Waltham, MA, 2018), we designed and produced a special Y-adapter with a polylactic acid medium using a 3D Printer (Monoprice, Rancho Cucamonga, CA, 2018) to permit side hole insertion of a disposable AmbuR aScopeTM three intubating bronchoscope (Columbia, MD, 2018) into a standard 40 Fr orogastric lavage tube (OGT). This allowed bronchoscope placement into the orogastric tube (OGT) with an air-tight seal and the ability to visualize through a distal side port. To simulate overdose, 50 pills (acetaminophen 500 mg/diphenhydramine 25mg tablet) were placed into the mannequin stomach with 200 mL of tap water. The mannequin was positioned in the left lateral decubitus position; the apparatus was assembled; and gastric lavage was accomplished with 2 L of tap water.
Result(s): We were able to easily visualize tube passage and placement into the stomach to an appropriate depth, appreciating an initially cloudy solution with numerous pill fragments. The adapted system then permitted lavage under constant bronchoscope visualization. Gastric contents were easily ascertained through the distal ports, and the stomach could be evaluated to the pylorus to exclude bezoars or remaining pill fragments. After lavage, a clear solution with no remaining evidence of pill slurry was evident. After extensive lavage, using the bronchoscope, only a small amount of pill fragments were visualized in the fundus.
Conclusion(s): This study demonstrates a proof of concept, linking visualization with OGT placement and active lavage. If these findings can be confirmed in vivo, our novel device may help clarify the indications, improve the safety and efficacy, and define the endpoints of orogastric lavage

Objective: Beta-adrenergic antagonists (BAAs) and calcium channel blockers (CCBs) negatively affect chronotropy and inotropy and are administered for many indications. The frequency of adverse reactions when BAAs and CCBs are administered concomitantly is infrequently described [1]. We reviewed the incidence of hemodynamic instability in patients in whom both a BAA and CCB were administered within a pharmacologically relevant time period.
Method(s): This was a quality improvement initiative in emergency department (ED) patients, performed at an urban, tertiary care hospital network from 1 October 2016 to 30 September 2018. Adult patients (>=18 years) who received both an intravenous BAA and CCB (in either order) within 6 hours were included. Primary outcomes were the incidence of bradycardia (heart rate <60 bpm) or hypotension (systolic blood pressure <90mmHg) after administration of the second medication. Secondary outcomes were associated diastolic blood pressure changes and administratively assigned primary and secondary diagnoses.
Result(s): Overall 56 ED patients met inclusion criteria. The median time between medication administration was 110 minutes for the cohort. The median decrease in pulse was 42 bpm. The median decrease in systolic blood pressure was 26mmHg, and the median diastolic blood pressure decrease was 11mmHg. According to the prespecified endpoints, 8.9% developed bradycardia, 8.9% developed systolic hypotension, and 17.9% developed either complication. These complications occurred at median times after second medication administration of 36 minutes for bradycardia and 10 minutes for hypotension. The most common diagnosis in patients who received concomitant BAA and CCB administration was atrial fibrillation (n= 39). All patients who developed bradycardia had atrial fibrillation (n= 4) or atrial flutter (n= 1). All patients who developed hypotension had atrial fibrillation (n= 5).
Conclusion(s): Despite a lack of published data, the administration of both BAAs and CCBs within 6 hours can cause significant hypotension and bradycardia in emergency department patients. Avoidance of concurrent administration of these medication classes or assurance of antidotal availability or pretreatment (i.e. with calcium salts) should be strongly encouraged