Faculty Bibliography

STUDY OBJECTIVE/OBJECTIVE:To assess the efficacy of 10mg intramuscular (IM) methadone in patients with opioid withdrawal syndrome (OWS). METHODS:This was a prospective observational, convenience sample of patients presenting to the ED with mild to moderate OWS. Evaluations included the Clinical Opiate Withdrawal Scale (COWS), Withdrawal Symptoms Scale (WSS), Altered Mental Status Scale (AMSS) and a physician assessment of the patient's WSS (MDWSS). After enrollment, 10mg of IM methadone was administered and patients were reassessed at 30min post-methadone administration. The primary outcome was the change in COWS at baseline and after methadone administration. Secondary outcomes were the differences between AMSS, and WSS post-methadone. RESULTS:Fifty-seven patients had COWS scores recorded at baseline and 30min. Fifty-six had mild to moderate OWS. The COWS improved a mean of 7.6 after methadone administration (P<0.001). The improvement was greater among patients presenting with moderate versus mild withdrawal (mean decrease=-9.1 vs. -5.5, P<0.001). Patients were more likely to self-score themselves as having withdrawal compared to MDs (93.6% vs. 76.6% respectively, P=0.027). Of the 62 patients with baseline and follow-up WSS by self-assessments, 69% improved post-methadone administration. In addition, the AMSS score remained the same or improved among 86% of cases with measurements at baseline and follow-up. CONCLUSION/CONCLUSIONS:A single IM dose of 10mg methadone in the ED reduces the severity of acute mild to moderate OWS by 30min. Larger prospective, randomized controlled, and blinded studies would be needed to confirm these results.

BACKGROUND: PCC (Kcentra(R)) is an Food and Drug Administration (FDA)-approved 4-factor PCC used for the treatment of warfarin-related coagulopathy (WRC), but it has also been used off-label to treat non-WRC. Three-factor PCC in the form of coagulation factor IX human (Bebulin(R)) has also been used for WRC and off-label to treat non-WRC. It is unclear whether the use of 3- or 4-factor PCCs is effective for the treatment of non-WRC,. OBJECTIVE: Our aim is to characterize the use of 3- and 4-factor PCCs for patients identified with a non-WRC. METHODS: A retrospective analysis of patients who received PCCs for both WRC and non-WRC between January 2012 and July 2015 was conducted. RESULTS: A total of 187 patients with elevated international normalized ratio (INR) who received PCCs were analyzed; 53.9% of patients in the WRC group and 27.7% in the non-WRC group corrected to an INR of 1.3 or less after 3- or 4-factor PCC administration. In those patients with non-WRC and who had underlying liver disease, 3- and 4-factor PCCs reduced mean INR by 0.98 and 1.43, respectively. CONCLUSION: Three and 4-factor PCCs can reduce INR in patients with WRC and in those with non-WRC secondary to liver disease.

BACKGROUND:Interest in tianeptine as a potential drug of abuse is increasing in the United States. We performed a retrospective study of calls to the New York State Poison Control Centers (PCCs) designed to characterize one state's experience with tianeptine. METHODS:Data were gathered from existing records utilizing the poison center data collection system, Toxicall® entered between 1 January 2000 through 1 April 2017. Information regarding patient demographics, reported dose and formulation of tianeptine, reported coingestants, brief narrative description of the case, disposition, and case outcome was collected. RESULTS:There were nine reported cases of tianeptine exposure. Seven were male with a mean age of 27. Three reported therapeutic use of tianeptine and five reported intentional abuse. One case was an unintentional pediatric exposure. Doses were reported in three cases; 12.5 mg in a pediatric unintentional exposure, and 5 and 10 g daily in the two reports of intentional abuse. Of note, five patients complained of symptoms consistent with opioid withdrawal. In one of two cases in which naloxone was administered, an improvement in mental status and the respiratory drive was noted. Outcomes reported in Toxicall® were minor in two cases, moderate in five cases, major in one case, and not reported in one case. CONCLUSIONS:These cases, reported to the New York State PCCs should alert readers to the potential for tianeptine abuse, dependence, and withdrawal.

Background: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS) and refractory cardiogenic shock. Patients with diphenhydramine overdose can develop severe cardiotoxicity, including wide-complex tachycardia leading to cardiac arrest. There are no reported cases of confirmed diphenhydramine poisoning successfully treated with ECMO Hypothesis: ECMO is effective in severe diphenhydramine poisoning with ARDS and refractory cardiogenic shock. Methods: Single-patient chart review. Case: An 18-year-old female with a history of depression was brought to the emergency department (ED) after being found unresponsive in her car with an empty package of diphenhydramine and empty bottle of ibuprofen Initial emergency medical services (EMS) vital signs were BP 60 mmHg/palp, HR 114 bpm, and RR 12 bpm. Bag-valve mask ventilation was initiated en route to the hospital. In the ED, the patient was unresponsive and then began actively seizing. Cardiac monitoring revealed a wide-complex tachycardia, and then the patient went into a pulseless electrical activity (PEA) cardiac arrest Return of spontaneous circulation occurred after 6 min of CPR during which she was intubated and received intravenous sodium bicarbonate, epi-nephrine, dextrose, calcium, and normal saline. Despite vasopressors and maximum ventilator support, the patient developed ARDS and refractory cardiogenic shock. She was placed on veno-arterial (VA) ECMO. The patient received VA ECMO for 3 days, then veno-venous (VV) ECMO for 11 days, and mechanical ventilation foratotalof21 days. Her course was complicated by rhabdomyolysis, acute kidney injury requiring dialysis, acute liver failure, and compartment syndrome of her left lower extremity necessitating fasciotomy. She was discharged to inpatient rehabilitation neurologically intact 30 days after presentation. A serum diphenhydramine concentration obtained in the ED on arrival was 6000 ng/mL (50-100 ng/mL). Acetaminophen, salicylate, and urine toxicology testing were all negative. Discussion: We believe this is the first case of confirmed diphenhydra-mine poisoning successfully treated with ECMO. This case report supports the use of ECMO in poisonings with cardiovascular collapse secondary to a cardiac toxin. Conclusion: ECMO can be used as a life-saving treatment modality in severe diphenhydramine overdose refractory to conventional therapy