The American journal of emergency medicine
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Dystonic reactions are extrapyramidal motor dysfunctions that result from an insufficient activity of nigrostriatal dopamine and present clinically as spasms of the various muscle groups. Neuroleptic drugs are a known cause of dystonia and are the most frequently encountered trigger. ⋯ Fewer reports of dystonia as a direct result of cocaine use, independent of neuroleptics, are found in the literature. The cases of two acute dystonic reactions secondary to cocaine use are presented, with a discussion of the pathophysiology and treatment alternatives.
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Thoracic aortic dissection is a rare but recognized complication of crack cocaine inhalation. It is thought to be triggered in some cases by transient severe elevations in blood pressure, causing a shear effect on the thoracic aorta. Unrecognized, it can result in high morbidity and mortality. A case of an unusual presentation of thoracic aortic dissection following crack cocaine ingestion is reported.
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A recently conducted observational study of the prehospital treatment of uncontrolled atrial fibrillation brought to light therapeutic inconsistencies by emergency providers in dealing with this dysrhythmia. A review of the literature suggests that digoxin lacks efficacy in controlling ventricular rate in atrial fibrillation and that the slow onset of digoxin makes its use in the emergency setting questionable. Because of their demonstrated ability to rapidly slow ventricular rate, the calcium channel blocker, diltiazem, or the beta-adrenergic blocker, esmolol, should be the preferred agents for treating rapid atrial fibrillation in the emergency department or the paramedic ambulance.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study.
Rapid tranquilization is a routinely practiced method of calming agitated psychotic patients by use of neuroleptics, benzodiazepines, or both in combination. Although several studies have examined the efficacy of the three approaches, none have compared these treatments in a prospective, randomized, double-blind, multicenter trial. Ninety-eight psychotic, agitated, and aggressive patients (73 men and 25 women) were prospectively enrolled during an 18-month period in emergency departments in five university or general hospitals. ⋯ Significant (P < .05) mean differences on the ABS (hour 1) and MBPRS (hours 2 and 3) suggest that tranquilization was most rapid in patients receiving the combination treatment. Study event incidence (side effects) did not differ significantly between treatment groups, although patients receiving haloperidol alone tended to have more extrapyramidal system symptoms. The superior results produced by the combination treatment support the use of lorazepam plus haloperidol as the treatment of choice for acute psychotic agitation.