Dr. Gustin's Blog

New Practice Guidelines on Carbon Monoxide Poisoning

The first consensus guidelines on how to evaluate, treat, and prevent carbon monoxide poisoning has recently been released and published in the American Journal of Repiratory and Critical Care Medicine.  These guidelines standardize management of carbon monoxide poisoning for clinician, toxicologist, and public health worker, and offer a road map to attorneys prosecuting or defending a carbon monoxide exposure legal action.  You can read more about  these guidelines by obtaining the actual article from the journal.  The citation is Hampson et al, Am J Respir Crit Care Med. 2012, October 18. epub, (ahead of print).  The title of the article is: Practice Recommendation in the Diagnosis, Management, and Prevention of Carbon Monoxide Poisoning.

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Death from Oxymorphone

Deaths due to narcotic abuse typically occur by overdose, and consequent respiratory failure.  New data demonstrates a novel cause of death associated with narcotic abuse.  On October 12, 2012 the US Food and Drug Administration (FDA) warned that individuals who abuse the prescription pain medication oxymorphone hydrochloride extended-release tablets (Opana ER, Endo Pharmaceuticals) are at serious risk of developing thrombotic thrombocytopenic purpura (TTP), a blood disorder that can result in kidney failure and death.

According to the FDA, cases of TTP linked to Opana appear to occur only when the drug is injected intravenously.

The FDA notes that in TTP, blood clots form in small blood vessels throughout the body. The clots can limit or block blood flow to the body’s organs, such as the kidneys, brain, and heart.

Platelets help the blood to clot. In TTP, as platelets form blood clots, fewer of them are available to assist with clotting in other parts of the body. This can lead to bleeding under the skin and internal bleeding.

TTP can cause death or lead to other complications with permanent damage, such as kidney failure, brain damage, or stroke.


FDA Adds 8 Potentially Hazardous Drugs to its Watch List

FDA Adds 8 Drugs to Watch List



The US Food and Drug Administration (FDA) has added 8 drugs to its list of products to monitor because of possible signs of serious risks or new safety information. The drugs treat conditions that include cancer, epilepsy, hypertension, and malaria.

The agency spotted yellow flags for the 8 drugs in the FDA Adverse Event Reporting System (FAERS) database during April, May, and June 2012.

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CT Scans Linked to Leukemia and Brain Cancer

Children undergoing computed tomography (CT) scans with cumulative radiation doses of about 50 mGy had about triple the risk for leukemia, and those who received doses of about 60 mGy had nearly triple the risk for brain cancer, according to the results of a retrospective cohort study published online June 7 in the Lancet.  Radiation exposure from CT scans in childhood could triple the risk of leukemia and brain cancer.

The study authors note that CT scans are very useful diagnostically, but that children are more radiosensitive than adults and may therefore have additional potential risks for cancer from ionizing radiation. The study goal was to determine the excess risk for leukemia and brain tumors after CT scanning in a cohort of children and young adults.

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Updated Guidelines for Subarachnoid Hemorrhages

The American Heart Association (AHA) Stroke Council and other professional societies collaborated on a new guideline for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH), based on a formal literature search of MEDLINE from November 1, 2006, through May 1, 2010. Topics highlighted in the guideline included incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, and anesthetic management during repair. Also covered were management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

The objective of this guideline by Connolly and colleagues was to provide recommendations for goal-directed treatment of patients with aSAH. Although aSAH is a serious medical condition, early, aggressive, and expert care can dramatically affect the outcome.

The 5 new class I (level B) recommendations are as follows:

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Ultrasound Gel Contaminated with Bacteria

Bacteria has a proclivity for finding any medium that can support its growth.  That includes the gel that is used by ultrasonographers to perform routine ultrasounds.  Normally the skin acts as a decent barrier against microbials but not always.  Staphylococcal organisms have a tendency to find their way through the skin barrier and can cause superficial or deep skin infections.  Sterile technique and good habits are necessary to prevent contamination of these biologic media.  The following report details the recently discovered contamination of ultrasound gel:

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Opiate Analgesic Deaths and Medical Malpractice

Opiates are prescribed regularly by physicians in all medical specialities for pain.  Patients frequently request opiates from their physicians when they are in pain.  Recent studies show a trend of increasing prescriptions.  Opiates, when taken in excess, or when they are taken on a regular basis, create addiction, by causing tolerance, that phenomenon where increasing doses of the medication are necessary to ameliorate the pain.  Opiate addiction increases the risk of overdose and death.  Opiate-related overdose and death has increased dramatically over the past few years, and now surpasses deaths from heroin and cocaine combined.  Physicans may be in violation of acceptable standards of practice by excessive prescribing and poor pain management practices.  The following study compares the use and abuse of opiate pain relievers by State.

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Emergency Rooms and New Stimulant Drugs

"Bath salts" are the latest designer drugs sending patients to the emergency department (ED). Unlike traditional bath salts that are added to bath water for a relaxing soak, these drugs, which can be ingested, inhaled, or injected, contain cardiovascular and central nervous system (CNS) stimulants such as 3,4 –methylenedioxypyrovalerone (MDPV) or 4-methylmethcarhinone (mephedrone). The drugs were initially sold over-the-counter under a number of different names. Patients using the drugs present to the ED with signs of acute stimulant overdose.

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Emergency Medicine Malpractice Avoidance

The following is a noteworthy article appearing in the Journal of Emergency Medicine, volume 41, issue 6, 2011.  Emergency physicians who have not had an opportunity to read it will find it helpful to their practice.  Because emergency medicine is a high risk speciality with regards to malpractice litigation, most emergency physicians adjust their practice so as to avoid situations that could lead to a medical malpractice lawsuit.  Moreover, most ER physicians live with a certain sense of unease because of the uncertainty and unpredictability of the emergency room environment, and the perception that it is just a matter of time before some adverse outcome leads to a lawsuit.  Read the article in its entirety.

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