1995 Called - They Want Your Boring Lectures Back Bringing Tech into the Classroom

Transcription

1 1995 Called - They Want Your Boring Lectures Back Bringing Tech into the Classroom Corey Heitz, MD Department of Emergency Medicine

2 Who is apprehensive about using newer teaching technologies?

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4 Why?

5 Sage on the Stage

6 Guide by the side

7 Practicality?

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9 Audience Response Systems iclicker Turning Point PollEverywhere SMSPoll

10 ARS Options for use Pretest Break up the monotony Needs assessment Letting the learners guide the lecture (more later ) Post test Learner survey

11 iclicker, Turning Point Used by several Carilion departments; can be obtained from OCPD Live results on the fly questions Assign clickers to learners Use apps, web instead of clickers $$$

12 questions

13 Text-based systems Use SMS to get responses Flexibility! Tiered pricing plans (start with free!)

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15 Choose your own adventure Enhancing imagery

16 Hyperlinking in PowerPoint Create text Highlight the text Right click and choose hyperlink Select document -> anchor -> locate

17 What medication? Uses and other examples of this med? How does it work?(therapeutic effects?) How does it cause EKG changes? What are presenting signs/ symptoms? What are predictors of badness? Treatment? Workup? What do you do with em?

18 Toxicology: Cyclic Antidepressants and SSRIs Corey Heitz, MD Adapted from: J. Michael Ballester, MD

19 Plan TCAs and SSRIs Background and Demographics Pathophysiology Pharmacokinetics Pharmacodynamics Clinical Presentation Symptoms Signs Workup Treatment Prevent Absorption Antidote Enhance Elimination Disposition Pharmacokinetics and pharmacodynamics: if you don t get em, you should demand them!!! SEROTONIN SYNDROME

20 TCAs Background Used to treat: depression, ADHD, panic disorder, social anxiety disorder, neuropathic pain, eating disorders Used less commonly now

21 TCAs Decreasing Use Antidepressants increased the risk compared to placebo of suicidal behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders. Narrow therapeutic index Lethal in overdose Equally effective options available

22 TCAs Demographics Still Out There! Antidepressants #4 cause of adult toxicological deaths (#7 overall) 12,270 exposures reported, 86 deaths (2004) TCAs responsible for ~2/3 of antidepressant deaths Amitriptyline (Elavil ) is #1 TCA offender Prototype Patient: Age >19, sex, intentional/suicidal OD

23 TCAs Pharmacokinetics Administration: Oral (± Intramuscular) Absorption: well absorbed from GI tract [Peak plasma] = 2-12 hours Metabolized in liver by cytochromes Active metabolites Transport: highly protein-bound in plasma and tissues Distribution: lipophilic Elimination (T½ hours? hours?) Small amount biliary Urinary

24 TCAs Pharmacodynamics Therapeutic mechanism reuptake of norepinephrine (NE) and serotonin (5-HT) Toxicity?

25 TCAs Pharmacodynamics Pathologic mechanism BLOCKS CARDIAC SODIUM AND POTASSIUM CHANNELs Strong anticholinergic activity Antagonist at α adrenergic receptors Antihistamine

26 TCAs Clinical Presentation CNS Cardiovasc Autonomic Other Delirium QRS bowel sds Hyperthermi a Coma S-Tach Urinary ret Acidosis Myoclonus 1 o AV block sweating Rhabdo Seizures R Axis Dev Pupils V-Tach Hypotension Anticholinergic Toxidrome!

27 TCAs Cardiac Effects Pentel R and Keyler DE. Cyclic Antidepressants. In: Ford, ed. Clinical Toxicology. 1 st ed. P516.

28 TCAs Cardiac Effects Pentel R and Keyler DE. Cyclic Antidepressants. In: Ford, ed. Clinical Toxicology. 1 st ed. P516.

29 TCAs EKG

30 TCAs Lethal badness on the rhythm strip

31 TCAs Workup CBC, BMP, urine tox screen (with ASA and APAP), serum osms, EKG Where appropriate: ABG, urine HCG, TCA level, CXR, CPK/myoglobin Rule out other reasons for pt s presentation

32 TCAs Supportive Care ABCDE, IV/O 2 /monitors, first and always More to come...

33 TCAs Prevent Absorption Gastric lavage? Probably not Activated charcoal? Maybe so MDAC? No Whole bowel irrigation? No

34 TCAs Block Effect NaHCO 3 Most effective intervention for cardiotoxicity of TCAs Mechanism? Indicated for any QRS > msec Dose? 50 meq (1 amp) IV, repeat until QRS <140 msec and hypotension resolved, or arterial ph 7.5

35 TCAs Supportive Care ABCDE, IV/O 2 /monitors, first and always Coma Protect airway with intubation if needed Delirium Benzos (dealer s choice) Seizures More benzos or barbiturates (dealer s choice) What drug to avoid? Hyperthermia Rapid cooling measures Hypotension IV fluid challenge first Treat dysrhythmias with NaHCO3 Dopamine or Norepi if above fail

36 TCAs Enhance Elimination Hemodialysis? No (lipophilic, large V D ) Hemoperfusion? No Urinary alkalinization? No

37 TCAs Disposition 6 hours with completely normal EKG, VS Psych Symptomatic ICU Cardiac monitoring until QRS < 100 msec Long-term sequelae Death or complete recovery

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39 SSRIs Background Introduced in 1980s as safer alternative to TCAs Prototype is fluoxetine (Prozac ), first was fluvoxamine (Luvox, 1983) Others: paroxetine (Paxil ), sertraline (Zoloft ), citalopram (Celexa ) Used for depression, ADHD, anxiety disorders, obsessivecompulsive disorder, chronic pain conditions, PTSD, panic disorder

40 SSRIs Demographics Antidepressants most commonly prescribed class of medications in USA SSRIs most commonly prescribed class of antidepressants 2004: 48,204 exposures reported, 103 deaths Prototype patient: same as TCA

41 SSRIs Pharmacokinetics Administration: oral Absorption: well absorbed from GI tract [Peak plasma] = 6-8 hours Metabolized in liver by cytochrome P-450 system Only active metabolite: norfluoxetine Transport: highly protein-bound in plasma and tissues Distribution: lipophilic Elimination (T½ 1-16 days?) Urinary

42 SSRIs Pharmacodynamics Decreases reuptake of serotonin by the presynaptic neuron Serotonin s exact role as a moodenhancing neurotransmitter is unclear

43 SSRI Overdose Clinical Presentation Mild or none after overdose Drowsiness and LOC most common Less common: dizziness, headache, hypotension, nausea/vomiting, tachycardia, tremor, agitation Rare: seizures, dysrhythmias (QRS wide) Occur with the atypicals (venlaxafine, sertraline, bupoprion)

44 SSRIs Workup CBC, BMP, UA, HCG, EKG, UDS If known SSRI OD, look for coingestants If unknown LOC or seizure, follow the appropriate workup for that DDx No levels to check...

45 SSRIs Treatment Supportive care Gastric Lavage? Probably not Activated Charcoal? Maybe MDAC? No WBI? No Seizures Benzos Phenobarb EKG Changes Monitoring Antidote? None Bicarbonate?

46 SSRIs Disposition Rarely a need for hospitalization in pure SSRI overdose Ψ Sequelae ~ø

47 Enhancing Images

48 Enhancing Images No m/r/g

49 Enhancing Images Decreased ROM

50 Enhancing Images Why is my elbow talking?

51 Enhancing Images What is he talking about?

52 Beyond PowerPoint ws.nearpod.com FGHJW