The use of non-contrast CT urography is recommended in the initial investigation of patients with ureteric colic.
Naltrexone is a long acting opioid receptor antagonist used in controlled opioid withdrawal drug programmes. When taken by an opioid dependent patient an acute withdrawal reaction will be precipitated. The case is presented where a known opioid drug misuser inadvertently ingested naltrexone in conjunction with heroin resulting in severe agitation, requiring heavy sedation followed by general anaesthesia to enable investigation and management of his clinical condition. N altrexone is a long acting opioid receptor antagonist used in drug rehabilitation programmes to maintain opioid abstinence. However, when consumed in conjunction with an opioid substance, prolonged opioid withdrawal will be precipitated resulting in unpredictable and life threatening medical consequences. We present a case where a known drug misuser consumed naltrexone in conjunction with heroin. CASE REPORTA 39 year old man presented to the accident and emergency department having taken up to three, 50 mg tablets of naltrexone and having smoked an unknown quantity of heroin. He was known to be an injecting drug user and to suffer from epilepsy. No other recreational drugs, alcohol, or prescribed medications were known to have been consumed. On arrival he was extremely agitated being restrained by four police officers. He was confused, sweating, with episodes of profuse projectile diarrhoea and vomiting. Glasgow Coma Scale was 12 (spontaneous eye opening, localising to pain, and using inappropriate speech). Pupils were dilated but reactive to light. Heart rate was regular at 180 beats/minute and respiratory rate 40 breaths/minute. Blood pressure, oxygen saturation, blood glucose, and temperature were normal. There was no evidence of head injury and no history of seizure. Urea, electrolytes, full blood count, and arterial blood gas measurements were normal. Initial attempts at sedation using a combination of titrated intravenous midazolam and droperidol were unsuccessful. After receiving a total of 20 mg midazolam and 15 mg droperidol he continued to be confused, agitated, and increasingly violent. An urgent CT head scan was arranged to exclude any intracranial pathology. To expedite this he was anaesthetised and ventilated. Rapid sequence induction of anaesthesia was carried out using 200 mg propofol, and 100 mg suxamethonium. Anaesthesia was maintained with a propofol infusion and incremental paralysis with atracurium.CT of his brain was normal. A lumbar puncture was performed while the patient was still anaesthetised. This showed no abnormality. The patient was extubated four hours after induction and transferred to the medical high dependency unit for observation. Further episodes of agitation occurred overnight requiring additional sedation with intravenous midazolam. The following morning he took his own discharge. Retrospectively urine toxicology screen confirmed the presence of cannabinoids, benzodiazepines, and opioids.
Dislocation of the shoulder joint is a common presentation in the emergency department, the reduction of which is usually performed under sedation. At present post-reduction x rays are taken after the patient has recovered from this sedation. If reduction is unsuccessful, repeated attempts under further sedation may be required. In this small case series, bedside ultrasound was found to be accurate in determining whether reduction had been successful.
The present study aimed at investigating the influence of personality on both anticipatory stress vulnerability and the effectiveness of coping strategies in an occupational stressful context. Following assessment of individual personality traits (Big Five Inventory), 147 volunteers were exposed to the anticipation of a stressful event. Anxiety and cardiac reactivity were assessed as markers of vulnerability to anticipatory stress. Participants were then randomly assigned to three groups and subjected to a 5-min intervention: relaxation breathing, relaxation breathing combined with cardiac biofeedback, and control. The effectiveness of coping interventions was determined through the cardiac coherence score achieved during the intervention. Higher neuroticism was associated with higher anticipatory stress vulnerability, whereas higher conscientiousness and extraversion were related to lower anticipatory stress vulnerability. Relaxation breathing and biofeedback coping interventions contributed to improve the cardiac coherence in all participants, albeit with greater effectiveness in individuals presenting higher score of openness to experience. The present findings demonstrated that personality traits are related to both anticipatory stress vulnerability and effectiveness of coping interventions. These results bring new insights into practical guidelines for stress prevention by considering personality traits. Specific practical applications for health professionals, who are likely to manage stressful situations daily, are discussed.
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