Annals of emergency medicine
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Buprenorphine induction for treating opioid use disorder is being implemented in emergency care. During this era of high-potency synthetic opioid use, novel and divergent algorithms for buprenorphine induction are emerging to optimize induction experience, facilitating continued treatment. ⋯ We present data from clinical studies of buprenorphine induction and propose a neuropharmacologic working model, which posits that acute clinical success of buprenorphine induction (achieving a positive agonist-to-withdrawal balance) is a nonlinear outcome of the opioid balance at the time of initial buprenorphine dose and mu-opioid-receptor affinity, lipophilicity, and mu-opioid-receptor intrinsic efficacy (the "ALE value") of the prior opioid. We discuss the rationale for administering smaller or larger doses of buprenorphine to optimize the patient induction experience during common clinical situations.
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Validated prediction rules identify febrile neonates at low risk for invasive bacterial infection. The optimal approach for older febrile infants, however, remains uncertain. ⋯ Although invasive bacterial infections were uncommon among febrile infants 2 to 6 months in the emergency department, the approach to diagnosis and management varied widely between sites. Therefore, evidence-based guidelines are needed to reduce low-value testing and treatment while avoiding missing infants with invasive bacterial infections.
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Rattlesnake envenomation can result in significant cutaneous and hematologic toxicity. While Cotalidae polyvalent immune Fab (ovine) antivenom (marketed as CroFab) was available for years, it is associated with increased late hematologic toxicity compared with its predecessor. Consequently, Crotalidae Immune F(ab')2 equine antivenom [marketed as Anavip; F(ab')2AV] has been recently become available. ⋯ Ultimately, his platelets reached a post-antivenom nadir of 65,000/μL. He was observed closely as an outpatient without additional antivenom, and ultimately had normalization of his platelets (211,000/μL) 20 days post envenomation. This case is one of the first cases demonstrating an inability to achieve control of the hematologic toxicity following Southern Pacific rattlesnake envenomation after treatment with F(ab')2AV.
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Editorial Comment
Pediatric Procedural Sedation and Laryngospasm: How Much Should I Worry?