Objectives Opioid pain reliever (OPR) prescribing at Emergency Department (ED) discharge has increased in the past decade but specific prescription details are lacking. Prior ED OPR prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study was to utilize a research consortium to analyze the characteristics of patients and opioid prescriptions using a national sample of ED patients. We also aimed to examine the indications for OPR prescribing, characteristics of opioids prescribed both in the ED and at the time of discharge, and characteristics of patients who received OPRs compared with those who did not. Methods This observational, multi-centered, retrospective cohort study assessed OPR prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18-90 years discharged with an OPR (excluding tramadol) were individually abstracted via standardized chart review by investigators for detailed analysis. Descriptive statistics were generated. Results During the study week, 27,516 patient visits were evaluated in the consortium EDs. 19,321 (70.2%) were discharged and 3,284 patients (11.9% of all patients and 17.0% of discharged patients) received an OPR prescription. For those prescribed an OPR, mean age was 41.1 (SD 14.7) years and 1,694 (51.6%) were female. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with OPR prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common OPRs prescribed were oxycodone (52.3%), hydrocodone (40.9%) and codeine (4.8%). >99% were immediate release, 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (IQR=12-20) respectively. Conclusion In a study of ED patients treated over a single week across the country, 17% of discharged patients were prescribed OPRs. The majority of the prescriptions had small pill counts and almost exclusively immediate release formulations.
A 19-year-old man with a history of past suicide attempts presented to the emergency department (ED) with severe abdominal pain. The patient's sister stated that, 30 min prior to presentation, the patient had tried to kill himself by drinking "poison." Per the patient, he drank about 120 mL of a cleaning agent immediately prior to informing his sister. The patient then had one bout of blood-tinged vomiting, so the sister activated emergency medical services (EMS). EMS arrived and transported the patient uneventfully to the ED while establishing an IV en route. Upon arrival to the ED, the patient had a pulse rate of 80/min, blood pressure of 150/90 mmHg, respiratory rate of 18/min, and oxygen saturation of 99% on room air.Soon after arrival to ED, the poison control center was contacted by the emergency medicine physician. By history, it was determined that the ingested cleaning agent was likely a brick-cleaning solution, although the ED staff were unable to definitively identify the composition at this time. The patient developed profound hematemesis within 15 min of arrival to the ED. He was endotracheally intubated for airway protection using 20 mg of etomidate and 5 mg of midazolam. Famotidine 40 mg IV was given and a propofol infusion was started for sedation. Due to the rapid progression of symptoms and recognition that many brickcleaning solutions contain hydrofluoric acid (HFA), the poison center specialist immediately forwarded the case to the medical toxicology consult service. Per telephone recommendation by the toxicology consultants, a nasogastric (NG) tube was placed and suction was started with minimal liquid return. This was followed by 30 mL of milk of magnesia given via the NG tube. An EKG was ordered, and a complete set of labs were sent including arterial blood gases. Ampules of 10% calcium gluconate were placed at bedside per toxicologist recommendation. One hour after presentation, initial lab results included pH 7.24, PaCO 2 46 mmHg, base excess −8 mEq/L, K + 7.4 mEq/L, and ionized Ca ++ 0.33 mEq/L (normal=1.15-1.29 mEq/L); the EKG showed sinus tachycardia at 106 with a QRS of 76 ms and a QTc of 406 ms. The combination of hypocalcemia, gastrointestinal distress, and a history of drinking "brick cleaner" heightened suspicion by the medical toxicology service for HFA ingestion. Two ampules (20 mL) of 10% calcium gluconate were then given IV over the next 30 min. The patient was then given one ampule (50 mL) of 8.4% sodium bicarbonate and an ampule (50 mL) of 50% dextrose along with 10
The objective of this report is to describe an acidemic patient with one of the largest recorded acetaminophen ingestions in a patient with acidemia who was treated with supportive care and intravenous (IV) N-acetylcysteine. A 59-year-old female with a history of depression was found comatose. In the Emergency Department, she was obtunded with agonal respirations and immediately intubated. Activated charcoal was given through a nasogastric tube. An initial acetaminophen serum level was 1141 mg/L. The patient was started on IV N-acetylcysteine. The acetaminophen level peaked 2 hours later at 1193 mg/L. She was continued on the IV N-acetylcysteine protocol. The next day her aspartate aminotransferase was 3150 U/L, alanine aminotransferase was 2780 U/L, and creatinine phosphokinase was 16,197 U/L. There was no elevation in bilirubin or international normalized ratio (INR). Transaminase levels decreased on day 3 and normalized by day 4 when she was transferred to a psychiatric unit. Few cases have been reported of strikingly elevated acetaminophen levels in poisoned patients who did not receive hemodialysis. These patients did have increased lactate levels, and some had normal liver function tests. All of these patients received N-acetylcysteine and survived the poisoning without sequelae. This patient in this report was unique in that she had the highest reported serum acetaminophen level with acidosis and was treated successfully with only IV N-acetylcysteine and supportive care.
Argos M, Kalra T, Rathouz PJ et al. Arsenic exposure from drinking water, and all-cause and chronic-disease mortalities in Bangladesh (HEALS): a prospective cohort study. Lancet 2010; 376:252-8 Background: Arsenic exposure from contaminated groundwater is a worldwide public health concern. An estimated 35-77 million people in Bangladesh have been chronically exposed to inorganic arsenic after installation of millions of deep tube wells intended to provide a pathogen-free water supply. Prospective investigation of an association between arsenic exposure and mortality with individual level data has not been performed. Research question: Is chronic arsenic exposure, as measured by repeated individual total urinary arsenic levels, associated with increased all-cause and chronic-disease mortality? Methods: A prospective cohort study was performed on adult (age 18-75 years) residents of Araihazar, Bangladesh. Study participants were recruited over a 2-year period and follow-up was performed biennially. Trained physicians blinded to arsenic concentrations in local well water utilized a verbal autopsy questionnaire and collected clinical samples. Well water was analyzed for arsenic concentration. A Cox proportional hazards model was used to analyze hazard ratios for mortality. Results: Eleven thousand seven hundred forty-six participants were recruited over the study period. Mean follow-up time was 6.5 years. Four hundred seven deaths were detected from the beginning of recruitment to the end of the follow-up period. Multivariateadjusted hazard ratios showed an increased risk of mortality at all concentrations of arsenic in well water. A one-quartile increase in arsenic concentration in well water was associated with 15% increase in all-cause mortality (95% CI 1.05-1.26). Recent change in exposure did not have a significant effect on mortality. Investigators estimated that over 20% of deaths could be attributed to elevated arsenic concentrations in drinking water. Conclusion: Chronic exposure to arsenic in well water was associated with increased all-cause and chronic-disease mortality. Critique: The method employed for measuring the concentration of urinary arsenic levels did not allow for speciation; therefore, estimation of nontoxic organic arsenic compounds such as arsenobetaine was unavailable. Arsenic dose was calculated in part by employing selfreported estimates of water intake. Furthermore, assigning the cause of death relied on accurate description of chronic diseases and symptoms in the deceased by relatives or neighbors. A longer follow-up period might better show the effects of remediation efforts, as subjects with decreasing urinary arsenic levels did not show a similar decline in mortality risk. Implication for toxicologists: This study highlights the consequences of an ongoing public health crisis. Strategies
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.