Biomedical subjects

P D Pearigen

Publications and source records attributed to P D Pearigen.

5 recordsLinked to original sources

PubMed1998

Resource-use analysis of a medical toxicology consultation service.

STUDY OBJECTIVE: To evaluate the impact of a medical toxicology consulting service (MTCS) on resource use and efficiency of care in patients hospitalized with a diagnosis of tricyclic antidepressant (TCA) poisoning. METHODS: We conducted a retrospective, case-controlled medical-records review at two urban tertiary care teaching hospitals. The study population comprised patients who presented to the emergency department with a diagnosis of TCA poisoning, in two phases. The first phase was longitudinal; we evaluated cases over 4 years before and after inception of an MTCS at one institution. In the second phase we compared consecutive cases of TCA poisoning treated at two urban teaching hospitals located within a mile of each other with similar patient populations, one with and one without MTCS backup. Inclusion criteria consisted of complete medical records, ingestion of first- and second-generation TCAs, and age greater than 16 years. Patients were excluded if history, physical examination, or laboratory analysis suggested that multiple substances had been ingested. Extensive demographic data were collected in each case. Clinical information obtained from each patient included admission vital signs, pupil size, QRS and corrected QT duration, and the presence of markers of severe TCA toxicity such as hypotension, seizures, pulmonary edema, respiratory insufficiency necessitating intubation, and the occurrence of antimuscarinic signs and symptoms. Information regarding treatment was also collected from each case, including laboratory tests, decontamination procedures, administration of sodium bicarbonate, and use of other medications and therapies. RESULTS: We identified a total of 88 patients in both phases of the study. Comparison groups were similar with respect to age, sex, presenting vital signs, presenting QRS and corrected QT duration, and incidence of recorded antimuscarinic signs, hypotension, seizures, and respiratory insufficiency requiring intubation. Total length of stay in a monitored hospital bed was also similar between groups. One fatality was recorded, but all other patients were discharged home or to a psychiatric facility. Patients seen by the MTCS consumed fewer health care resources in the form of less decontamination and fewer laboratory tests. CONCLUSION: The MTCS may provide a resource-efficient means of treating patients with TCA poisoning. A larger, multicenter study of a variety of poisoned patients should be undertaken to further investigate this issue.

Adolescent↗

PubMed1998

The crying infant.

The crying infant is a common presenting complaint and a difficult diagnostic dilemma that may represent the primary manifestation of a serious or even life-threatening condition. Although many children experience an exacerbation of the normal crying tendencies or minor ailments typical of the early months of life, a significant number of infants have underlying pathologic conditions requiring immediate intervention. This article briefly reviews current and past research on this phenomenon and presents differential diagnoses and recommendations for the evaluation and management of the acute crying episode.

Algorithms↗

PubMed1996

Unusual causes of abdominal pain.

Common and uncommon GI and other intraperitoneal illnesses may present in unusual ways. In addition, many systemic or extraperitoneal disease processes frequently include abdominal pain as a clinical manifestation. The clinician should suspect an unusual cause of abdominal symptoms in patients with repeated visits to the ED without a diagnosis, those who appear ill or complain of severe abdominal pain with disproportionately negative abdominal physical examination findings, those with constitutional or extraperitoneal symptoms or signs, and the elderly or immunocompromised. After initial resuscitation and stabilization have taken place, early evaluation of the need for urgent surgical evaluation and operative management is crucial in the patient with abdominal pain, even when the cause of the symptoms is unclear. A thorough history and careful and complete abdominal and nonabdominal physical examination, paired with appropriate but judicious diagnostic testing, are essential to detecting these unusual causes of abdominal pain and to preventing needless morbidity and mortality.

Abdominal Pain↗

PubMedDate not supplied

Transient myocardial dysfunction in a child with salicylate toxicity.

Aspirin overdose may result in acid-base disturbances, electrolyte abnormalities, pulmonary edema, chemical hepatitis, seizures, and mental status alteration, but myocardial depression has not been reported following aspirin overdose in children. In addition to these more typical features, the 13-month-old boy reported here developed clinical, radiographic, and echocardiographic evidence of myocardial impairment with pulmonary edema and moderately severe global left ventricular dysfunction (estimated shortening fraction of 23%). Complete resolution of the myocardial dysfunction was demonstrated on follow-up echocardiography as the child recovered from the aspirin intoxication. This case suggests that myocardial dysfunction can occur as a result of toxic aspirin ingestion, and that it may contribute to salicylate-induced pulmonary edema.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMedDate not supplied

Poisoning due to calcium antagonists. Experience with verapamil, diltiazem and nifedipine.

The calcium antagonists are a heterogeneous class of drugs which block the inward movement of calcium into cells through 'slow channels' from extracellular sites. By inhibiting phase 0 depolarisation in cardiac pacemaker cells and phase 2 plateau in myocardium, and by depressing calcium ion flux in smooth muscle cells of blood vessels, these agents may exert profound effects on the cardiovascular system, particularly in susceptible individuals or in overdose. Sinus node depression, impaired atrioventricular (AV) conduction, depressed myocardial contractility, and peripheral vasodilatation may result. Pharmacokinetic features of calcium antagonists include rapid and complete absorption from the gastrointestinal tract, with extensive first-pass hepatic metabolism yielding generally low bioavailability. The volume of distribution is generally large and protein binding is high. Elimination is almost entirely by the liver. Impaired renal function does not affect pharmacokinetics. Verapamil is the most potent inhibitor of cardiac conduction and contractility, with diltiazem also showing such effects. Nifedipine is the most potent vasodilator, but only occasionally impairs the sinus node or AV conduction. Significant pharmacodynamic effects are common during combination therapy with calcium antagonists, especially verapamil and beta-blockers. Verapamil may significantly elevate serum digoxin concentrations and may exert additive negative effects on chronotropism and dromotropism when this combination is used. Overdoses of calcium entry blockers are becoming more frequent and reflect an extension of the known pharmacodynamic profile of these agents. Typical features include confusion or lethargy, hypotension, sinus node depression and cardiac conduction defects. Onset of symptoms may be delayed if a sustained release preparation is ingested. Management of calcium antagonist overdose includes gut decontamination with lavage and activated charcoal. All symptomatic patients and patients with a history of ingesting a sustained release preparation should be admitted for ECG monitoring. If bradycardia and/or conduction defects contribute to hypotension, atropine or isoprenaline (isoproterenol) may accelerate the ventricular rate. Transvenous pacing may be required. Depressed myocardial contractility usually responds well to calcium chloride or calcium gluconate administration, but further inotropic support may be required. Peripheral vasodilation should be managed with intravenous fluids and a pressor agent such as dopamine or norepinephrine (noradrenaline).

Calcium Channel Blockers↗