Narcan Overdose. Too Much of a Good Thing?

What do smack, dragon, horse, salt, brown sugar, china white, and black pearl have in common? That’s right… they are all nicknames for heroin. We all know that Naloxone (Narcan) is a useful antidote in overdose, however appropriate dosing and timing can be more of an art than a science.   The most important conceptRead more

Opioid Substitution Therapy

ED physicians need to be comfortable with the various modalities of opioid substitution therapy (OST) and their associated complications.  We are all familiar with the patient who has missed a daily dose of methadone on the way to booking and is subsequently brought to the ED by corrections officers to address this issue.  A recentRead more

Gastric Emptying for Acute Poisonings

At the request of department leadership, we will be revisiting methods of gastric decontamination for today’s pearl.  Two methods in particular. Ipecac-induced emesis and gastric lavage are two procedures that we read about in medical school and in textbooks but never utilize in practice.  They are both considered techniques of “gastric emptying” (GE) as opposedRead more

Hot sauce!

Remember your chronic cannabinoid user that comes in with hyperemesis.   They have Cannabinoid hyperemesis syndrome (CHS): cyclic abdominal pain, nausea, and vomiting in the setting of chronic cannabis use. You try every anti-emetic  in your ED but still vomiting.  These patients usually get relief from hot showers but of course your patient already knows thatRead more

Doc… I’m drowning!

You are called to triage to assess a man for shortness of breath. Per EMS, this is a 46 year old male with a history of substance abuse and HTN, found by his wife this afternoon, overdosed on Heroin and barely breathing. EMS arrived on scene to find him unconscious, with a RR of 5Read more

Edible Arrangements: What You Need to Know About Edible Marijuana

In recent years, a number of states have decriminalized marijuana for medical use, and some have even decriminalized recreational use. This trend is likely to continue. Much of this marijuana – particularly when used recreationally – is consumed as edible products. For our last pearl together, we’ll talk about marijuana, edibles, and some important thingsRead more

Digoxin Day, Part 2: Digoxin and ECGs

Welcome to Digoxin Day, Part 2! Like all sequels, this is sure to be even better than the original.   Cardiac Physiology of Digoxin: Cardiac glycosides increase parasympathetic tone by acting on the vagus nerve. They also depress myocardial tissue. Together, these actions cause a decreased rate of depolarization through the SA node and aRead more

Digoxin Day, Part 1: Calcium and Hyperkalemia

Digoxin is a cardiac glycoside, and it has a narrow therapeutic window (0.5-2 ng/ml). Due to its sub-milligram dosing, its dependence on renal clearance, and its interactions with many other drugs, digoxin toxicity is a real concern for patients taking this medication.   Digoxin and hyperkalemia: Hyperkalemia is frequently seen in the presence of digoxinRead more

Opioid Prescriptions in the ED: How Many People Have You Hooked?

To call opioid use in the US a “problem” is a gross understatement, and most of us in Emergency Medicine appreciate this. You may believe that if you only prescribe a small number of pills to an opioid-naïve patient who is truly in pain, you are not causing harm. A new study in the NewRead more

Topical Toxicology: VX Gas and Kim Jong-nam

*Thanks to Dr. Clark Owyang for following this “case” with me!   On February 13, Kim Jong-un, son of Kim Jong-il and half-brother of current North Korean leader Kim Jong-un, was poisoned at Kuala Lumpur airport in Malaysia. He died shortly after. Yesterday, the Malaysian police reported that Kim Jong-nam died of exposure to VXRead more