# 98 When being backwards can be forward-thinking
Christine E. Whitten, MD, is the author of the popular book Anyone Can Intubate now in its fifth edition; she blogs at The Airway Jedi.
After a sedated procedure, when the pain and anxiety are relieved, the patient may "renarcotize" and slip deeper into sedation, possibly losing his airway and ventilatory drive. She writes in "Opioid Induced Respiratory Depression: A Balance in the Force."
"A more dangerous scenario can occur if the respiratory depression does not begin until the trip down the hallway to the recovery area has begun. During this trip the patient may be semi-sitting, with the face hidden from us as we push the gurney from behind. If the patient is hypoventilating, a vicious cycle can start."
In the ED setting, this destination may be an ordinary cubicle with a nurse carrying a full patient load who will need to settle the patient and then catch up with other tasks: frequency of acute observation may be lessened. C.f., Recognizing Airway Obstruction May Save Your Patient's Life.
EMS crews are usually two persons, facing each other with the patient in-between, during short travel with frame stretchers (no long handles) thus the patient is watched. Hospital wheeled stretchers may be awkward to push backwards due to length and steerability issues with swivel casters, yet it may be helpful when the patient must be continually watched by one person.
Go slow to avoid dizziness, and take bumps gently as the axle is directly under the patient. If the patient is at high risk, have a qualified airway manager also. When the patient nods off, typically the head will flex forward and cause obstruction; keep it in view, check actual airflow, open the airway, reevaluate.
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# 99 When “PM” should not mean post mortem
Some suicidal ingestions or gestures involve over the counter “sleeping aids.” Nearly all are the antihistamine: Diphenhydramine (two are Doxyllamine succinate). The toxidrome is mainly anticholinergic. Beware: gastric emptying may be delayed and ileus present make serial acetaminophen levels desirable.
Many “PM” analgesics or multi-symptom cold remedies are acetaminophen-diphenhydramine combinations. Other significant ingredients may be present. Read the actual labels, as famous “name brands“ may co-brand other drugs or combinations, and generic or private-house branding is common.
What I’ve noticed most is a peculiar AMS, an awake absence, internally preoccupied, looking about or reacting without comprehension or speech, with occasional irregular eye movements; when familiar, it points to the diagnosis as one walks through the door.
I’ve found sinus tachycardia and decreased blood pressure that don’t respond as expected to a fluid bolus. Absent bowel sounds, dry axillae and membranes further suggest the anticholinergic basis.
Contact your Poison Center. Treatment is supportive. Consider charcoal. Be alert for cardiac dysrhythmias. Consider Sodium Bicarbonate or Physostigmine. Be alert for seizures: control initially with benzodiazepines.
Situations where an initial nontoxic acetaminophen level may not be sufficient August 8, 2012 – ThePoisonReview.com.
Is hemodialysis effective in diphenhydramine overdose? December 27, 2010, - ThePoisonReview.com.
Abnormal eye movements in diphenhydramine poisoning (video) – January 24, 2011
ThePoisonReview.com. Posting links to NEJM’s video and case review.
Carstairs, S. D., & Schneir, A. B. (2010). Opsoclonus Due to Diphenhydramine Poisoning. New England Journal of Medicine, 363(27).
Anticholinergic Toxicity Treatment & Management. Author: John J Bruns Jr, MD, MPH,†; Chief Editor: Asim Tarabar, MD. Updated: Mar 27, 2014. emedicine.medscape.com