QUESTIONS and CONTROVERSIAL ISSUES

• What is the differential diagnosis of a patient with pinpoint (miotic) pupils?
• C = Cholinergic drugs, clonidine
• O= Opiates, Organophosphates
• P= Phenothiazines, pilocarpine, pontine bleed
• S= Sedative hypnotics
• What members of the "Coma Cocktail" should be administered to this patient?
• A) 50% Dextrose
• 1) Efficacious if patient is hypoglycemic
• 2) Theoretic exacerbation of cerebral ischemia
• 3) Check chemstick prior to administration.
• B) Thiamine
• 1) Indicated in alcoholic, malnourished patients.
• 2) Avoid precipitation of Wernicke's encephalopathy?
• C) Naloxone
• 1) Indicated in comatose patients with suspected drug overdose
• 2) Initial dose of 2mg IVP (restrain patient prior to administration since can precipitate withdrawal)
• 3) May require doses up to 10mg with longer acting opioids and higher grades of heroin
• 4) Short half life (20-30 minutes)
• 5) Naloxone drip if repeat boluses required

CLINICAL COURSE

After administration of 2mg of naloxone, the patient becomes more alert and begins to verbalize with spontaneous respiratory activity. His vital signs are stable with normal sinus rhythm noted on the monitor. Laboratory data including ECG and CXR are unremarkable. The toxicology screen is positive for opiates. The patient denies suicidal ideations and admits to frequent abuse of IV heroin claiming he "just had a bad cut tonight." He becomes more uncooperative and demands to be discharged.

• III) Should this patient receive a longer acting opioid antagonist?
• A) Nalmafene: opioid antagonist with 6 hour half life
• B) May be efficacious in patients requiring a naloxone drip
• C) Documentation in the emergency medicine literature limited
• D) Unclear whether indicated, efficacious or safe in narcotic users being discharged from the ED.
• IV) What are the indications for administering the benzodiazepine antagonist flumazenil in the setting of a toxicologic coma?
• A) Efficacious in the setting of acute benzodiazepine overdose
• B) Should not be regarded as the latest member of the "coma cocktail"
• C) Can potentially reverse the seizure-protecting properties of benzodiazepines in mixed drug ingestions (eg- TCAs)
• D) Patients who are chronic benzodiazepine abusers may demonstrate withdrawal seizures when given flumazenil