ACMT Toxicology Visual Pearl: The Heart Won’t Go On and On
Which cardiotoxic plant is shown?
- Lily of the valley
- Moonflower
- Morning glory
- Water hemlock
- White snakeroot
Which cardiotoxic plant is shown?
The venom from this pictured snail shares a primary mechanism of action with what other deadly toxin?
Which of the following is the most likely explanation for this skin lesion in a worker handling sheep hides?
(Photo credit: CDC/ James H. Steele, Public domain via Wikimedia Commons)
Are you using phenobarbital instead of benzodiazepines as the first-line monotherapy for patients in alcohol withdrawal in the Emergency Department (ED)? If not, you probably should be. Another old drug for a new indication, right? Well not exactly. Phenobarbital is indeed an older and relatively cheap drug (less than $20 per loading dose) that has gained some press recently for the treatment of acute alcohol withdrawal [1-3].
Phenobarbital used to be one of the standard treatments for ethanol (EtOH) withdrawal prior to the introduction of benzodiazepines. However, there are key advantages over benzodiazepines.
In short, yes. Several studies have indicated that dosing with phenobarbital (PO or IV) is safe and effective at decreasing the need for escalating doses of benzodiazepines for EtOH withdrawal [1-6]. In comparison to benzodiazepines, it demonstrated:
There is a dearth of evidence about which patients require medical admission in the setting of phenobarbital administration. The American Society of Addiction Medicine has developed a tool to assist providers with disposition planning for patients with alcohol withdrawal syndrome for all-comers (not necessarily those treated with phenobarbital) [2]. Their recommendations are as follows:
Phenobarbital has gained significant popularity for use in EtOH withdrawal in the last few years. Several factors make it ideal for use in EtOH withdrawal, primarily its long half-life allowing for a multi-day, self-tapering effect. The most commonly recommended dosing regimen starts with a 10 mg/IBW kg bolus followed by titration every 30 minutes afterwards. Patients in the ED often can be safely phenobarbital-loaded and discharged, assuming hemodynamic stability, normal alertness, and resolution of withdrawal symptoms. More rigorous studies are needed determine dose thresholds that warrant hospital admission.
Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.
After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.
To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.
Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique
For our case, this dual catheter compression technique succeeded in halting the bleed.
A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.
The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.
Figure 1. Anatomy of a zipper
Reported techniques for releasing zippers include [1, 2]:
All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.
The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.
Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)
Figure 3. Freed zipper body
A heavy alcohol drinker, who is well known to your Emergency Department, presents with altered mental status, except that he looks different this time. He looks really bad, stating that he has been vomiting blood. He is hypotensive. He then vomits a copious amount of blood right in front of you. You intubate the patient and initiate the massive transfusion protocol, but everything you pour into him seemingly comes right back out. The gastroenterologist on-call states that he is too unstable for endoscopy. It is time for a balloon tamponade device. You’ve trained for this and set up everything. You call the respiratory therapists (RT) for this mystical “manometer” that you have seen in instructional videos, except that they look puzzled by your request. It is time to MacGyver a method that allows you to know the esophageal balloon pressure that you are generating to avoid an esophageal rupture.
Esophageal Balloon Tamponade Devices – Linton-Nachlas, Sengstaken-Blakemore, Minnesota Tubes (image courtesy of Dr. Mark Ramzy at REBEL EM)
There are 2 commonly used devices for tamponading the esophagus during a variceal bleed, the Sengstaken-Blakemore (SB) tube and the Minnesota tube. There is also the Linton-Nachlas tube, but that only has a gastric balloon. The SB tube was created in 1950 in order to help tamponade variceal bleeds [1]. It is a 3-lumen device that has ports to inflate the gastric balloon, aspirate gastric contents, and inflate an esophageal balloon. The Minnesota tube was developed later as a variation to the SB tube and contains an additional port and lumen for aspirating esophageal contents [2]. Another minor difference is that the gastric balloon in the Minnesota tube holds 450-500 ccs of air, while the SB gastric balloon holds 250 ccs of air [2].
Indication: The uncontrolled hemorrhage from esophageal or gastric variceal bleeding after medical or endoscopic treatment fails, is not available, or is not technically possible [3, 4].
Contraindications [4]:
Esophageal balloon tamponade devices achieve hemostasis in 60-90% of cases; however, they are only a temporary measure of hemorrhage control because over 50% of variceal bleeds rebleed after deflation [5].
The following instructions are for inserting a Sengstaken-Blakemore (SB) tube [3, 6]:
The manometer referenced in numerous videos [6, 8] is actually a cuff manometer, or pressure gauge, to measure endotracheal cuff pressures. Hence, the RT’s are supposed to have them. In our emergency department, the RTs do not spend a lot of time going around measuring cuff pressures and usually save that until the patient reaches the ICU. It is convenient to use for the inflation of the esophageal balloon because it can inflate and measure pressure at the same time.
Pearl 1: Check the units of pressure being used. Manometers often use cmH2O, while esophageal balloons use mmHg.
Pearl 2: While the gastric balloon sets a target VOLUME, the esophageal balloon sets a target PRESSURE.
Once the inflated gastric balloon is confirmed to be in place, it is time to inflate the esophageal balloon. A manual blood pressure instrument can be repurposed to inflate and measure the esophageal balloon pressure.