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case presentation 18

The Call. You respond to a 9-1-1 call at the home of a middle-aged couple. The woman called 9-1-1 because her husband, Sammie, is

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case presentation 18

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    1. Case Presentation #18

    3. Initial Assessment Middle-aged Asian male complaining left sided chest pain ABC’s intact Glacow Coma Scale = 15

    4. Focused History & Exam Patient gives a 2 hour history of “hard” (7 on a scale of 10) left-sided chest pain that began while he was watching TV. The pain radiates to the jaw, is associated with nausea, but no vomiting, and is unrelieved by NTG.

    5. Pertinent Findings Massively overweight male with continuing c/o chest pain Vital signs: B/P – 210/105, RR – 22, HR – 126 Pulse Ox: 98% on room air HEENT: Pupils – 6mm and reactive Neck: no JVD Chest: no wall tenderness

    6. Pertinent Findings (cont.) Heart: tachycardia Lungs: clear, no râles Extremities: no edema Neuro: alert & oriented Skin: warm & dry Past Medical History: Angina, usually relieved by NTG. Hypertensive and weighs 150 Kg

    7. Medications Nitrogycerine – prn Altace – 10 mg q.d. Norvasc – 5 mg q.d. Aspirin – 81 mg q.d. Pt. Has also been taking a “nutritional supplement” for the past 5-6 days to help with weight loss

    8. EKG

    9. Initial Treatment Non-rebreather mask 100% O2 IV Normal Saline TKO Nitroglycine sl. - titrated to pain and blood pressure Morphine sulfate - titrated to pain Transport to the closest hospital

    10. Hospital Findings Anxious, middle-aged Asian Male Vital signs: B/P – 162/96, RR – 18, HR – 118 Pulse Ox: 99% on room air Temp: 98.4º p.o. Physical findings remain the same

    11. Lab Studies CBC: 13.1 K H & H: 16.2 / 49.3 Usual “chemistries”: wnl Troponin I: 3.1 mg/ml (normal < 1.0 mg/ml) Myocardial Troponin T: 4.6 mg/ml (normal < 1.0 mg/ml) Nutritional supplement found to contain “Ephedra”

    12. MI Algorithm

    13. WHO Criteria Must meet 2 out of 3 criteria Clinical history of ischemic type chest pain > 20 minutes Changes on serial ECG tracings Rise and fall of serum cardiac enzymes (biomarkers)

    14. Hospital Outcome Nitroglycerine drip Beta blocker Aspirin Emergency percutaneous transluminal coronary angioplasty (PTCA) and stent placement Discharged 4 days later

    15. Discussion Was this a “garden variety” myocardial infract? What was the role of the nutritional supplement?

    16. EPHEDRA Ephedra sinica Ephedra alkaloids Ma Huang County mallow Desert herb Herbal ecstasy Yellow horse

    17. History & Uses Evergreen shrub native to China and Mongolia Grows to 20” in height, has long narrow stems and small leaves Used in Chinese medicine for over 5000 years Ephedrine, the active alkaloid, was isolated in 1877; formerly used in may prescription and OTC medications

    18. History & Uses (cont.) Pharmaceutical companies switched to psuedoephedine (Sudafed) in the 1950’s due to ephedrine’s side effects Uses: Chinese – chills, fever, cough, wheezing Western – asthma, cough, hay fever, to raise blood pressure, weight loss, euphoria, increased athletic performance

    19. History & Uses (cont.) Often marketed as a legal alternative to ecstasy Readily available on the internet in many forms Advertised heavily

    21. The Warning Label!

    22. Side Effects Sympathomimetic stimulant

    23. Case Studies - fatalities 20 year old man took eight, instead of two, “Ultimate Xphoria” pills 35 year old woman used ephedra for weight loss for 11 days prior to having an MI A Boston college student drank an ephedrine-containing protein drink and had an MI A 32 year old baseball pitcher died from hyperthermia

    24. FDA Requirements A full warning label In general, safe dose is: Ephedrine - 8 mg/dose, maximum 24 mg/day Ephedra - 25 mg/dose, maximum 100 mg/day The FDA recently declared ephedra “dangerous at any dose”

    25. What does the literature say? Prevalence: Blank HM, Khan LK, Serdula MK. JAMA 2001 : Aug 22-29; 268 (8) 930-5 A random-digit telephone survey of 14,679 adults showed that 7% used OTC diet pills (2% PPA, 10% ephedra). Use of products was especially high (28.4%) in young, obese women.

    26. More Literature Pharmacology: Haller CA, Jacob P, Benowitz NL. Clinical Pharmacology Therapy 2002 : June; 71(6) 421-32 Eight healthy adults took one dose of a supplement containing 20 mg ephedrine alkaloids and 200 mg caffeine. Systolic B/P increased 14 mm Hg at 90 minutes. HR increased 15 BPM at 6 hours

    27. …and more More Pharmacolocy: Haller, CA Benowitz NL NEJM 2000 : December 21; 343 (25) 1833-8 140 reports to the FDA of adverse events related to ephedra were reviewed. 62% of cases were considered to be definitely, probably, or possibly related to ephedra use. 47% of symptoms were cardiovascular and 18% involved CNS. 10 events resulted in death 13 produced permanent disabilities

    28. Conclusions Many “herbal” or “nutritional” supplements are harmful Patients are more likely to exceed the recommended dosages of herbal remedies than with prescription medications Be aware of potential drug interactions between supplements and prescription drugs Always specifically ask patients about the use of supplements and other OTC medications

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