Traditional teaching recommends naloxone doses of at least 0.4 mg IV to reverse opioid toxicity. Drs. Lewis Nelson (@LNelsonMD) and Mary Ann Howland (@Howland_Ann) co-authored the opioid antagonist chapter in Goldfrank’s Toxicologic Emergencies.¹ They write:

“However, this dose [0.4 mg] in an opioid-dependent patient usually produces withdrawal, which should be avoided if possible. The goal is to produce a spontaneously and adequately ventilating patient without precipitating significant or abrupt opioid withdrawal. Therefore, 0.04 mg is a practical starting dose in most patients, increasing to 0.4 mg, 2 mg, and finally 10 mg.”

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Ceftriaxone is a broad-spectrum antibiotic that is frequently administered intramuscularly (IM) in emergency medicine. However, these injections hurt — A LOT! Can we do anything to minimize the pain?

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Valproic acid is used for a variety of clinical indications including seizures, migraine prophylaxis and treatment, and bipolar disorder. A metabolite of valproic acid, thought to be propionic acid, has the ability to increase ammonia levels by inhibiting a step in the hepatic urea cycle, which may lead to valproic acid-induced hyperammonemic encephalopathy. As a result, patients treated with valproic acid presenting with signs and symptoms of acute mental status changes, increased seizure frequency, and/or gastrointestinal symptoms should be evaluated for elevated ammonia concentrations.

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Carbon monoxide (CO) poisoning may be the most common cause of fatal poisonings worldwide. ¹ The majority of poisonings occur in the Fall and Winter. It is that time of year when heaters that have lain dormant all summer are flicked on, sometimes in enclosed areas, introducing CO fumes into homes. The pathophysiology is complex, and not fully understood, but all ED physicians should be aware of the signs and symptoms of CO toxicity, and know how to treat it.

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