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Annjeannette Geib - One of the best experts on this subject based on the ideXlab platform.

  • combined butalbital acetaminophen caffeine overdose case files of the robert wood johnson medical school toxicology service
    Journal of Medical Toxicology, 2012
    Co-Authors: Christopher Bryczkowski, Annjeannette Geib
    Abstract:

    A 40-year-old woman with no previous medical problems presented to the Emergency Department (ED) 2 h after ingesting an unknown amount of Fioricet® (butalbital/acetaminophen/caffeine), oxycodone, and fentanyl patches about 90 min prior to emergency medical service (EMS) dispatch. The patient’s husband reported they had had a fight, and he went down to the basement; when he came back upstairs, he found the patient unconscious with an empty pill bottle. A call to the patient’s pharmacy by ED staff revealed that the patient had her prescription for butalbital/acetaminophen/caffeine tablets refilled 5 days earlier and that she had convinced the pharmacist to override the refill amount to dispense 540 tablets; according to the pharmacist, the patient stated she was going on a trip to Italy and needed a 6-month supply. EMS personnel removed a fentanyl patch (unknown strength) from her skin. The source of the fentanyl and the strength and formulation of the oxycodone were not recorded. Prehospital treatment included naloxone 4 mg IV without any noticeable clinical response, insertion of a nasal trumpet, and initiation of bag-valve-Mask ventilation. A fingerstick glucose was 137 mg/dL. On arrival to the ED, the patient was unconscious with the following vital signs: blood pressure, 98/54 mmHg; pulse, 72 beats/min; respiratory rate, 14 breaths/min; and pulse oximetry, 100 % on a Non-Rebreather Mask. Auscultation of her chest revealed clear but bilaterally diminished breath sounds and a regular cardiac rhythm without murmurs, rubs, or gallops. The patient’s ventilation improved with jaw thrust, but, due to increased secretions, she was intubated within 10 min of ED arrival using etomidate and succinylcholine. On further examination, she had palpable distal pulses, and her abdomen was soft and non-tender. The patient’s pupils were 1–2 mm in diameter and sluggishly reactive to light. The patient was noted to be shivering prior to being fully exposed, and her skin was warm and dry, revealing no signs of traumatic injuries. An ECG revealed a normal sinus rhythm at 86 beats per minute with a prolonged QTc interval (504 ms). An orogastric tube and Foley catheter were both inserted, with a large volume (700 cc) of dark-colored urine quickly filling the Foley bag. Activated charcoal 50 g was administered via orogastric tube. Due to the reported large ingestion of acetaminophen and some initial uncertainty about the time of ingestion, an IV N-acetylcysteine (NAC) infusion was started according to the 21-h protocol, prior to obtaining serum acetaminophen level results. About 90 min after arrival (3 h after ingestion), the patient began having massive diuresis, producing 5,800 cc of urine over 1 h. Due to concerns about the patient’s reported fentanyl patch ingestion and the lack of knowledge regarding possible extendedThis project was not funded.

  • Combined Butalbital/Acetaminophen/Caffeine Overdose: Case Files of the Robert Wood Johnson Medical School Toxicology Service
    Journal of medical toxicology : official journal of the American College of Medical Toxicology, 2012
    Co-Authors: Christopher Bryczkowski, Annjeannette Geib
    Abstract:

    A 40-year-old woman with no previous medical problems presented to the Emergency Department (ED) 2 h after ingesting an unknown amount of Fioricet® (butalbital/acetaminophen/caffeine), oxycodone, and fentanyl patches about 90 min prior to emergency medical service (EMS) dispatch. The patient’s husband reported they had had a fight, and he went down to the basement; when he came back upstairs, he found the patient unconscious with an empty pill bottle. A call to the patient’s pharmacy by ED staff revealed that the patient had her prescription for butalbital/acetaminophen/caffeine tablets refilled 5 days earlier and that she had convinced the pharmacist to override the refill amount to dispense 540 tablets; according to the pharmacist, the patient stated she was going on a trip to Italy and needed a 6-month supply. EMS personnel removed a fentanyl patch (unknown strength) from her skin. The source of the fentanyl and the strength and formulation of the oxycodone were not recorded. Prehospital treatment included naloxone 4 mg IV without any noticeable clinical response, insertion of a nasal trumpet, and initiation of bag-valve-Mask ventilation. A fingerstick glucose was 137 mg/dL. On arrival to the ED, the patient was unconscious with the following vital signs: blood pressure, 98/54 mmHg; pulse, 72 beats/min; respiratory rate, 14 breaths/min; and pulse oximetry, 100 % on a Non-Rebreather Mask. Auscultation of her chest revealed clear but bilaterally diminished breath sounds and a regular cardiac rhythm without murmurs, rubs, or gallops. The patient’s ventilation improved with jaw thrust, but, due to increased secretions, she was intubated within 10 min of ED arrival using etomidate and succinylcholine. On further examination, she had palpable distal pulses, and her abdomen was soft and non-tender. The patient’s pupils were 1–2 mm in diameter and sluggishly reactive to light. The patient was noted to be shivering prior to being fully exposed, and her skin was warm and dry, revealing no signs of traumatic injuries. An ECG revealed a normal sinus rhythm at 86 beats per minute with a prolonged QTc interval (504 ms). An orogastric tube and Foley catheter were both inserted, with a large volume (700 cc) of dark-colored urine quickly filling the Foley bag. Activated charcoal 50 g was administered via orogastric tube. Due to the reported large ingestion of acetaminophen and some initial uncertainty about the time of ingestion, an IV N-acetylcysteine (NAC) infusion was started according to the 21-h protocol, prior to obtaining serum acetaminophen level results. About 90 min after arrival (3 h after ingestion), the patient began having massive diuresis, producing 5,800 cc of urine over 1 h. Due to concerns about the patient’s reported fentanyl patch ingestion and the lack of knowledge regarding possible extendedThis project was not funded.

James W. Goldfarb - One of the best experts on this subject based on the ideXlab platform.

  • Effects of supplemental oxygen on cardiovascular magnetic resonance water proton relaxation time constant measurements (T1, T2 and T2*).
    Magnetic resonance imaging, 2019
    Co-Authors: James W. Goldfarb, Brittany Hsu, Jie J. Cao
    Abstract:

    Abstract Objective To study, the effects of supplemental oxygen on the measurement of native cardiovascular water proton relaxation time constants using commercially available protocols. Methods T1, T2 and T2* relaxation time constant mapping were performed in twelve volunteers at 1.5 T breathing room air and supplemental oxygen supplied by nasal cannula and a Non-Rebreather Mask. Regions-of-interest were drawn for quantitative measurements in the bloodpool of each ventricle and atria as well as septal myocardium. The effects of supplemental oxygen were investigated statistically using a mixed model analysis of variance. Intra- and inter-observer reproducibility were assessed using the Intraclass Correlation Coefficient and Coefficient of Variation. Results Blood T1 relaxation time constants in the left ventricle (T1 change = −241.0 ms) and left atrium (T1 change = −247.0 ms) decreased significantly in every subject after oxygen inhalation with a Non-Rebreather Mask (p  Conclusion Supplemental oxygen does not affect myocardial relaxation time constant measurements with current protocols. On the other hand, blood T1 measurements with the inhalation of supplemental oxygen supplied by a Non-Rebreather Mask change significantly and could affect myocardial tissue characterization if used for the calculation of extracellular volume. Additionally, current relaxation time constant mapping protocols do not reproducibly detect myocardial T1 changes with supplemental oxygen inhalation.

  • Effect of supplemental oxygen on native blood and myocardial MOLLI T1 relaxation times
    Journal of Cardiovascular Magnetic Resonance, 2015
    Co-Authors: James W. Goldfarb, Kathleen Gliganic, Nathaniel Reichek
    Abstract:

    Background Magnetic resonance (MR) T1 relaxation time measurements are increasingly used for myocardial tissue characterization. Significant differences in native and gadolinium-enhanced measurements have been associated with ischemic and non-ischemic cardiomyopathies, myocardial fat deposition, fibrosis and edema as well as regional and global ventricular functional parameters. Supplemental oxygen is often given to cardiac MR patients for improved breatholding. High flow supplemental oxygen with a Non-Rebreather Mask is reported to reduce both myocardial and blood T1 relaxation times and has been studied with HASTE and FLASH T1 relaxation measurements for the optimization of MR ventilation scanning. The primary mechanism is dissolved oxygen acting as a paramagetic contrast agent. Conversely other reports show an increase of blood T1 times with increasing oxygen saturation. We studied the effect of supplemental oxygen on myocardial and blood T1 relaxation times using a well-documented T1 MOdified Look-Locker Imaging (MOLLI) protocol. Methods Twelve healthy subject without respiratory or cardiac disease (age: 47.4±5.3 years; 6 male) were studied at 1.5T using MOLLI T1 mapping (TE/TE= 2.8/1.2 ms; 3(3)-5; 2 inversions, 3 heartbeat rest period; TI start=120 ms; TI increment=120ms; 3 parameter curve fitting). Images were acquired in the four chamber view. Five measurements spaced by 10 minutes were performed with supplemental oxygen supplied by nasal cannula and a non-reberather Mask alternating with room air (M1: Room air, M2: nasal oxygen (2 l/m), M3: Room air, M4: Non-Rebreather Mask (15 l/m), M5: room air). Regions-of-interest were drawn for T1 measurements in the boodpool of each ventricle and atria as well as septal myocardium. The effects of supplemental oxygen were investigated statistically using a mixed model analysis of variance.

Christopher Bryczkowski - One of the best experts on this subject based on the ideXlab platform.

  • combined butalbital acetaminophen caffeine overdose case files of the robert wood johnson medical school toxicology service
    Journal of Medical Toxicology, 2012
    Co-Authors: Christopher Bryczkowski, Annjeannette Geib
    Abstract:

    A 40-year-old woman with no previous medical problems presented to the Emergency Department (ED) 2 h after ingesting an unknown amount of Fioricet® (butalbital/acetaminophen/caffeine), oxycodone, and fentanyl patches about 90 min prior to emergency medical service (EMS) dispatch. The patient’s husband reported they had had a fight, and he went down to the basement; when he came back upstairs, he found the patient unconscious with an empty pill bottle. A call to the patient’s pharmacy by ED staff revealed that the patient had her prescription for butalbital/acetaminophen/caffeine tablets refilled 5 days earlier and that she had convinced the pharmacist to override the refill amount to dispense 540 tablets; according to the pharmacist, the patient stated she was going on a trip to Italy and needed a 6-month supply. EMS personnel removed a fentanyl patch (unknown strength) from her skin. The source of the fentanyl and the strength and formulation of the oxycodone were not recorded. Prehospital treatment included naloxone 4 mg IV without any noticeable clinical response, insertion of a nasal trumpet, and initiation of bag-valve-Mask ventilation. A fingerstick glucose was 137 mg/dL. On arrival to the ED, the patient was unconscious with the following vital signs: blood pressure, 98/54 mmHg; pulse, 72 beats/min; respiratory rate, 14 breaths/min; and pulse oximetry, 100 % on a Non-Rebreather Mask. Auscultation of her chest revealed clear but bilaterally diminished breath sounds and a regular cardiac rhythm without murmurs, rubs, or gallops. The patient’s ventilation improved with jaw thrust, but, due to increased secretions, she was intubated within 10 min of ED arrival using etomidate and succinylcholine. On further examination, she had palpable distal pulses, and her abdomen was soft and non-tender. The patient’s pupils were 1–2 mm in diameter and sluggishly reactive to light. The patient was noted to be shivering prior to being fully exposed, and her skin was warm and dry, revealing no signs of traumatic injuries. An ECG revealed a normal sinus rhythm at 86 beats per minute with a prolonged QTc interval (504 ms). An orogastric tube and Foley catheter were both inserted, with a large volume (700 cc) of dark-colored urine quickly filling the Foley bag. Activated charcoal 50 g was administered via orogastric tube. Due to the reported large ingestion of acetaminophen and some initial uncertainty about the time of ingestion, an IV N-acetylcysteine (NAC) infusion was started according to the 21-h protocol, prior to obtaining serum acetaminophen level results. About 90 min after arrival (3 h after ingestion), the patient began having massive diuresis, producing 5,800 cc of urine over 1 h. Due to concerns about the patient’s reported fentanyl patch ingestion and the lack of knowledge regarding possible extendedThis project was not funded.

  • Combined Butalbital/Acetaminophen/Caffeine Overdose: Case Files of the Robert Wood Johnson Medical School Toxicology Service
    Journal of medical toxicology : official journal of the American College of Medical Toxicology, 2012
    Co-Authors: Christopher Bryczkowski, Annjeannette Geib
    Abstract:

    A 40-year-old woman with no previous medical problems presented to the Emergency Department (ED) 2 h after ingesting an unknown amount of Fioricet® (butalbital/acetaminophen/caffeine), oxycodone, and fentanyl patches about 90 min prior to emergency medical service (EMS) dispatch. The patient’s husband reported they had had a fight, and he went down to the basement; when he came back upstairs, he found the patient unconscious with an empty pill bottle. A call to the patient’s pharmacy by ED staff revealed that the patient had her prescription for butalbital/acetaminophen/caffeine tablets refilled 5 days earlier and that she had convinced the pharmacist to override the refill amount to dispense 540 tablets; according to the pharmacist, the patient stated she was going on a trip to Italy and needed a 6-month supply. EMS personnel removed a fentanyl patch (unknown strength) from her skin. The source of the fentanyl and the strength and formulation of the oxycodone were not recorded. Prehospital treatment included naloxone 4 mg IV without any noticeable clinical response, insertion of a nasal trumpet, and initiation of bag-valve-Mask ventilation. A fingerstick glucose was 137 mg/dL. On arrival to the ED, the patient was unconscious with the following vital signs: blood pressure, 98/54 mmHg; pulse, 72 beats/min; respiratory rate, 14 breaths/min; and pulse oximetry, 100 % on a Non-Rebreather Mask. Auscultation of her chest revealed clear but bilaterally diminished breath sounds and a regular cardiac rhythm without murmurs, rubs, or gallops. The patient’s ventilation improved with jaw thrust, but, due to increased secretions, she was intubated within 10 min of ED arrival using etomidate and succinylcholine. On further examination, she had palpable distal pulses, and her abdomen was soft and non-tender. The patient’s pupils were 1–2 mm in diameter and sluggishly reactive to light. The patient was noted to be shivering prior to being fully exposed, and her skin was warm and dry, revealing no signs of traumatic injuries. An ECG revealed a normal sinus rhythm at 86 beats per minute with a prolonged QTc interval (504 ms). An orogastric tube and Foley catheter were both inserted, with a large volume (700 cc) of dark-colored urine quickly filling the Foley bag. Activated charcoal 50 g was administered via orogastric tube. Due to the reported large ingestion of acetaminophen and some initial uncertainty about the time of ingestion, an IV N-acetylcysteine (NAC) infusion was started according to the 21-h protocol, prior to obtaining serum acetaminophen level results. About 90 min after arrival (3 h after ingestion), the patient began having massive diuresis, producing 5,800 cc of urine over 1 h. Due to concerns about the patient’s reported fentanyl patch ingestion and the lack of knowledge regarding possible extendedThis project was not funded.

Kai Kuck - One of the best experts on this subject based on the ideXlab platform.

  • A comparison of ventilation with a non-invasive ventilator versus standard O_2 with a nasal cannula for colonoscopy with moderate sedation using propofol
    Journal of Clinical Monitoring and Computing, 2019
    Co-Authors: Mike Fogarty, Derek Sakata, Lara Brewer, Ken Johnson, John C. Fang, Kai Kuck
    Abstract:

    The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a faceMask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion Mask. The Mask had a built-in leak to facilitate CO_2 clearance during CPAP. Patients in the control group received 2–10 L/min of oxygen via nasal cannula or Non-Rebreather Mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p 

  • A comparison of ventilation with a non-invasive ventilator versus standard O2 with a nasal cannula for colonoscopy with moderate sedation using propofol.
    Journal of clinical monitoring and computing, 2019
    Co-Authors: Mike Fogarty, Lara Brewer, John C. Fang, Joseph A. Orr, Derek J. Sakata, Ken B. Johnson, Kai Kuck
    Abstract:

    The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a faceMask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion Mask. The Mask had a built-in leak to facilitate CO2 clearance during CPAP. Patients in the control group received 2-10 L/min of oxygen via nasal cannula or Non-Rebreather Mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p < 0.001). There were no desaturation events observed in the 29 patients in the intervention group. In contrast, 27 out of 156 patients in the control group experienced a desaturation event. Average AUC of patients in the control group was 70%-s (time (s) * oxygen saturation below < 90%) (95% CI 32.34-108.60%) whereas the average AUC in intervention group patients was 0%-s (% time (s) * oxygen saturation < 90%) (95% CI 0-0%), p = 0.01. This preliminary study found that CPAP via a tight-fitting Mask may be an effective tool to reduce the incidence and duration of obstructive apneic events as well as hemoglobin oxygen desaturation during lower endoscopy procedures that use propofol and fentanyl for sedation.Clinical Trial Registration ClinicalTrials.gov ID: NCT02623270. https://clinicaltrials.gov/ct2/show/NCT02623270 .

Mathilde Lermuzeaux - One of the best experts on this subject based on the ideXlab platform.

  • Continuous Positive Airway Pressure (CPAP) face-Mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study.
    PloS one, 2020
    Co-Authors: Sophie Alviset, Quentin Riller, Jerome Aboab, Kelly Dilworth, Pierre Alain Billy, Yannis Lombardi, Mathilde Azzi, Luis Ferreira Vargas, Laurent Laine, Mathilde Lermuzeaux
    Abstract:

    Introduction Because of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients. Material and methods This single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a Non-Rebreather Mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation. Results CPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated. Conclusions CPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation.

  • Continuous positive airway pressure face-Mask ventilation to manage massive influx of patients requiring respiratory support during the SARS-CoV-2 outbreak
    2020
    Co-Authors: Sophie Alviset, Quentin Riller, Jerome Aboab, Kelly Dilworth, Pierre Alain Billy, Yannis Lombardi, Mathilde Azzi, Luis Ferreira Vargas, Laurent Laine, Mathilde Lermuzeaux
    Abstract:

    Background: Since December 2019, a global outbreak of coronavirus disease (COVID-19) is responsible for massive influx of patients with acute respiratory failure in hospitals. We describe the characteristics, clinical course, and outcomes of COVID-19 patients treated with continuous positive airway pressure (CPAP) in a large public hospital in France. Method: It is a single centre retrospective observational cohort. From 27th March to 23rd April, consecutive patients receiving 10 to 15 l/min of oxygen with a Non-Rebreather Mask, who had signs of respiratory failure or were unable to maintain an SpO2 > 90%, were treated by CPAP with a face-Mask unless the ICU physician judged that immediate intubation was indicated. The main outcome under study was reasons for CPAP discontinuation. Results: A total of 585 patients were admitted in Delafontaine hospital for COVID-19. ICU was quickly overwhelmed. Fifty-nine out of 159 (37%) patients requiring ICU care had to be referred to other hospitals. CPAP therapy was initiated in 49 patients and performed out of ICU in 41 (84%). Reasons for discontinuation of CPAP were intubation for invasive ventilation in 25 (51%) patients, improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%). A decision not to intubate had been taken for the 2 patients who died while on CPAP. Conclusions: Treatment with CPAP is feasible and safe in a non-ICU environment in the context of a massive influx of patients. One third of these patients with high oxygen requirements did not eventually need invasive ventilation.