February 25, 2021

Background: Opioid-related emergency department visits have been increasing over the past two decades in correlation with increasing rates of heroin use in the United States. Naloxone, which is used to reverse heroin overdose, has a half-life of approximately 60 to 90 minutes (2). A 4 to 6 hour observation period after naloxone reversal has typically been recommended to account for a duration of 5 half-lives of naloxone, and Goldfrank’s Toxicologic Emergencies recommends several hours of observation following naloxone reversal of heroin overdose (2). Systematic reviews have recommended as low as a 1-hour observation period (3). However, early discharge may be dangerous given both the short half-life of naloxone and the possibility that the purported heroin may have been adulterated or may have been another substance entirely, such as fentanyl analogs. This study attempted to determine the safety of a 2-hour observation period after naloxone administration for heroin overdose, which was chosen based on the half-life of naloxone.

October 10, 2020

From Oct 6th – 8th, 2020, Haney Mallemat (@CriticalCareNow) and his team put on an absolutely amazing online critical care conference called ResusX Rewired.  ResusX is a conference designed by resuscitationists to provide clinicians with the most up to date skills and knowledge to help make a difference in your patients' lives.  Haney and his crew made a combination of short-format, high-yield lectures, and completely customizable small group sessions with procedural demos seem easy.  There were so many high-quality speakers and pearls that I learned from this conference that I wanted to archive them here in one post for reference and to share with our readers/followers.

October 1, 2020

Background Information: Cannabinoid Hyperemesis Syndrome (CHS) is characterized by the chronic use of cannabis paired with nausea, recurrent vomiting episodes and diffuse abdominal pain.1 The pathophysiology of CHS remains unclear and large systematic reviews of the literature have recommended up to 9 differing mechanisms as to why it occurs.2 The duration of cannabis use in CHS also widely varies with the majority of patients reporting daily use and beginning use early in life.2 In addition to the history of frequent cannabis use, patients’ self-reported relief of symptoms following hot showers or baths helps distinguish CHS from other cyclic vomiting syndromes. Treatment typically involves cessation of cannabis use however the authors of this randomized controlled pilot study wished to investigate the use of topical capsaicin cream when compared to placebo.

September 16, 2020

Take Home Points

  • Wernicke encephalopathy is characterized by ataxia, altered mental status and ophthalmoplegia but patients are unlikely to have all these components
  • Suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms
  • Prophylactic administration of thiamine 100 mg IV/IM to at risk patients can prevent development of the disease
  • Once Wernicke encephalopathy has developed, it must be treated with high-dose, IV thiamine

May 28, 2020

Background Information:

Physicians have and continue to heavily contribute to the current opioid epidemic in the United States and Canada.1 Although much of the focus has been opioid prescriptions given to patients in the emergency department,2,3 not much attention has been paid to critically ill patients who survive to hospital discharge. The long-term sequelae of these opioids is concerningly overlooked especially when physicians utilize these medications as part of an “analgesia first” approach to sedating critically ill patients for the purposes of invasive mechanical ventilation (IMV).4 Previous observational studies in Canada found that approximately 85% of critically ill patients receiving IMV were exposed to opioids.1 Furthermore, the average daily opioid dosing for 2-7 days was 63 milligrams of morphine equivalent (MME), increasing to 106 MME per day for patients receiving IMV for greater than 7 days. The authors of this study performed a retrospective chart review of population-based data from Ontario Canada to investigate the frequency of new opioid initiation and persistent opioid use among critically ill patients who received mechanical ventilation. They compared this to patients who were hospitalized but not critically ill.
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