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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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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