EM Cases - Dr. Allen

- Chloral hydrate is an oral sedative that has a narrow therapeutic profile, used for insomnia, anxiety and in pediatric sedation. Most common side effects of toxicity are depressed mental status and coma, nausea and vomiting, and cardiac instability with dysrhythmias. 

- Cardiac tissue becomes hypersensitive to catecholamines in chloral hydrate exposure, making epinephrine in ACLS and catecholaminergic pressors dangerous. Treat dysrhythmias with propranolol, 1-2mg IV over 5 minutes. 

- COPD ventilatory drive transitions to being triggered by hypoxia from hypercarbia. Hyperoxia can result in depressed respiratory rate, though this is not noted at lower FiO2. Use caution with administration of higher FiO2 oxygen in severe COPD patients. 

- Benzodiazepine overdose can be reversed with flumazenil, though caution should be used given risk of seizure precipitation. Goldfrank’s indications for use in OD are CNS depression, normal VS (including SaO2), normal ECG and otherwise normal neuro exam.

- Spinal cord stimulators and other neurostimulators cause ECG artifact when electrical impulses are not parallel to ECG leads. Some may be turned off with magnets or remotes; avoid turning off stimulators if placed for dystonia. 

- Spontaneous retropharyngeal hematoma is a rare entity, though potentially life threatening. Classic triad (Capp’s Triad) is tracheoesophageal compression (dysphagia, odynophagia, hoarseness), anterior tracheal displacement, and anterior neck bruising.

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