J Emerg Med
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Emergency patients are frequently assigned nonspecific diagnoses. Nonspecific diagnoses describe observations or symptoms and are found in chapters R and Z of the International Classification of Diseases, 10th edition (ICD-10). Patients with such diagnoses have relatively low mortality, but due to patient volume, the absolute number of deaths is substantial. However, information on cause of short-term mortality is limited. ⋯ More than half of ambulance patients released within 24 h from the ED with nonspecific diagnoses, and who subsequently died within 30 days, died unexpectedly. One-fourth died from a pre-existing terminal illness. Patients dying unexpectedly were old, treated with polypharmacy, and often life-threateningly sick at arrival.
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Methamphetamine is a commonly used illicit substance. The route of administration is usually parenteral, oral ingestion, or snorting. A less common route of administration is placing in the rectum. ⋯ A 28-year-old man presented to the emergency department with acute methamphetamine toxicity within 30 min after intentional rectal administration of methamphetamine for recreational purposes. The patient had hypertension, tachycardia, drug-induced psychosis, elevated creatine kinase, and required rapid sequence intubation and admission to the intensive care unit. Our patient had no clinical evidence of bowel ischemia or injury at the time of discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rectal administration of methamphetamine is known as "plugging," "booty bumping," "keestering," and "butt whacking." The rectal administration of methamphetamine has the increased risk of severe acute methamphetamine toxicity, as rectal administration bypasses first-pass metabolism, allowing for a more acute onset and higher bioavailability of methamphetamine compared with oral administration. There is the potential for mesenteric ischemia and bowel injury after rectal methamphetamine. Close clinical monitoring for bowel and rectal ischemia or injury are recommended, in addition to management of the sympathomimetic toxidrome.
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Anticholinergic toxicity is commonly encountered in the emergency department. However, the availability of physostigmine, a central acetylcholinesterase inhibitor used to reverse anticholinergic delirium, has been significantly limited due to national drug shortages in the United States. Several articles have explored the viability of rivastigmine as an alternative treatment in these patients. ⋯ A 33-year-old man presented to the emergency department after a suspected suicide attempt. The patient was found with an empty bottle of diphenhydramine at the scene. On arrival, he was tachycardic and delirious, with dilated and nonreactive pupils and dry skin. As the clinical picture was highly suggestive of anticholinergic toxicity, the patient was treated with oral rivastigmine at a starting dose of 4.5 mg to reverse his anticholinergic delirium. Although a repeat dose was required, his delirium resolved without recurrence. Why Should an Emergency Physician Be Aware of This? Oral rivastigmine has been applied successfully here and in other case reports to reverse anticholinergic delirium with the benefit of prolonged agitation control. Emergency physicians may consider this medication in consultation with a specialist, with initial doses starting at 4.5-6 mg, if encountering anticholinergic delirium when physostigmine is not available.