Post Conference Letter, 8/20/08
Another fine conference at the ‘hurst; thanks to our presenters — Matt C, Dr. Chung, Dr. Ginsburg, Dr. Iavicoli, and Dr. Chason, and thanks to all for the good turnout.
Let’s start with Tox, since we had a brief preview (perhaps too brief) of our new cyanokit and its use. More below:
— Since cyanide poisoning is rare and often requires a good deal of suspicion to make the diagnosis, it’s wise to review — check the references under the ‘reference’ tab above, or eMedicine’s take, or this readable Emergency Med Magazine writeup. Remember: MUDPILES is a great mnemonic, but it leaves out the ‘C’ for Cyanide. And a lactate over 10 mmol/L in a smoke inhalation case, or greater than 6 mmol/L after a suspected pure cyanide poisoning, suggests significant cyanide exposure.
– If you have a low suspicious of cyanide poisoning, give traditional thiosulfate — it’s safe.
– More likely cyanide poisonings should receive thiosulfate and cyanokit. Cyanokit setup and dosing is explained, naturally, at cyanokit.com. Be sure to draw labs as the cyanokit will make blood testing of creatinine and other tests impossible, for days.
– the Lily kits, which are not being replaced, also contain amyl nitrate and sodium nitrate. These were always controversial and are no longer going to be used here.
– Dr. Ginsburg gave a great overview of recognizing and managing medication-induced hypoglycemia. I think a key point in her talk was that sulfonylureas like glipizide and glyburide need some sugar to trigger their enhanced insulin secretion — so if a patient has taken too much glipizde but skipped a meal, they might be ok. It’s when they get an amp of D50 or eat a twinkie that their insulin levels spike then blood sugar plummets. Be wary of this yo-yo effect, because the impulse is to treat it with more D50.
– The best way to break the cycle is octreotide, which among other things prevents insulin secretion. While it’s been accepted (and shown to be of benefit in retrospective studies) to give octreotide in cases of recurrent hypoglycemia, a recent prospective study of hypoglycemic diabetics on sulfonylureas in Annals (Francis et al, April 2008) showed that, when 75mcg of octreotide is added to standard therapy (one amp of d50 and some food), recurrent hypoglycemia episodes were reduced.
– Our protocol is therefore to give 50 mcg of octreotide q6 x4 upon the first recurrent hypoglycemic episode… or to start right away with it in cases where close monitoring of FSBS is unlikely. However, you’ve got to tell your medicine colleagues that octreotide use must continue for 24 hours and the patient must be watched while off octreotide an additional 24 hours — these sulfonylureas can really linger.
There was lots to love about Dr. Chung’s hyperbarics lecture. We’ll cover some more of this ground in board review but for now I just want to note:
– The Martini Effect (nitrogen narcosis in a depth-dependent manner secondary to nitrogen’s impairment of nerve conduction) is real, though PubMed doesn’t recognize the term. The assertion that every 10m of depth is equivalent to a martini is unproven, however.
– Using a blood-pressure cuff on a painful limb in decompression sickness (the bends) is a smart idea: you push the nitrogen bubbles out of muscles and tendons and back into solution, easing pain. Unfortunately it’s not sensitive or a particularly helpful therapy (Rudge, 1991).
Many thanks to Drs. Iavicoli and Chason for their perspectives on emergency management. We’ll be posting the resident disaster plan and contact chain soon, under the ‘Policies’ tab above. In the meantime, here are some important sources to consult in the event of an emergency:
– the Red Cross “Safe & Well” site — tell friends and family that you’re ok.
– NYC Medical Reserve (free login)
– 1010 WINS online
– For more planning resources: NYC DOH, Ready New York and Ready.gov
Posted
on Saturday, August 23rd, 2008 at 9:50 pm by Nick. Filed under
Post-Conference Letter, Useful Links, Toxicology, Blog.
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