No abstract

What is known and objective A large percentage of opioid overdose fatalities involve fentanyl or one of its legal or illegal analogs (F/FAs). Is there something about the pharmacology of these drugs that make them unusually dangerous in an overdose? Comment Some of the reasons for the dangers of overdose of F/FAs is their high potency and low cost (that leads to wide distribution). But it is rarely asked if the basic pharmacology of F/FAs differ in some fundamental way from conventional opioids such as morphine and heroin. In addition to centrally mediated respiratory depression via opioid receptors, F/FAs cause rigidity in the key respiratory muscles of the chest, upper airway and diaphragm (“wooden chest syndrome,” WCS) by a non‐opioid mechanism. What is new and conclusion WCS is an atypical pharmacology of F/FAs. Because of its rapid onset and non‐opioid mechanism, WCS makes F/FA overdose particularly dangerous.

Acute limb ischemia (ALI) is a limb-threatening and life-threatening disease process. Mural aortic thrombosis (MAT) is a rare cause of ALI. While there is limited evidence on the use of bedside ultrasound for the detection of ALI or MAT, duplex ultrasound remains the standard in the diagnosis and ultimate medical decision-making in patients with acute and chronic limb ischemia. Point-of-care ultrasound may be used in the evaluation of patients with signs and symptoms of this disease entity. This is a case of a 79-year-old female with a complicated medical history, who presented with a pulseless right leg and abdominal tenderness. The patient quickly decompensated requiring intubation for airway protection. A post-intubation arterial blood gas (ABG) was unsuccessfully attempted in the right femoral artery, prompting an ultrasound-guided ABG. On B-mode ultrasound evaluation, echogenic material was visualized in the right common femoral artery without evidence of Doppler flow signal. Additionally, a partially obstructing echogenic material was also noted at the femorosaphenous vein junction with only partial compressibility by compression sonography. A computed tomography angiography of the aorta was performed indicating extensive infrarenal aortic thrombosis. The patient expired despite the relatively prompt diagnosis, highlighting the importance of early identification of acute arterial occlusion.Keywords Mural aortic thrombus Á Acute limb ischemia Á Point-of-care ultrasound Á Bedside ultrasound Á Arterial thrombus Á Deep vein thrombosis Riassunto L'ischemia acuta degli arti inferiori (ALI) è una malattia che mette in pericolo gli arti e la vita stessa del paziente. La trombosi parietale dell'aorta (MAT) è una causa rara di ALI. Mentre vi è una limitata evidenza sull'uso dell'ecografia al letto del paziente per la rilevazione di ALI o MAT, il Doppler rimane lo standard nella diagnosi e nel processo decisionale medico finale, in pazienti con ischemia acuta e cronica degli arti. L'ecografia può essere utilizzata nella valutazione dei pazienti con segni e sintomi di questa malattia. Presentiamo il caso di una donna di 79 anni, con una complicata storia clinica che si è presentata senza polso nella gamba destra e tensione addominale. La paziente si scompensava rapidamente, richiedendo l'intubazione per la protezione delle vie respiratorie. Dopo l'intubazione è stato tentato un arterial blood gas test (ABG) nell'arteria femorale destra, senza successo spingendo verso un ABG con guida ecografica. La valutazione ecografica in B-mode ha evidenziato materiale ecogeno nell'arteria femorale comune destra senza evidenza di segnali Doppler. Inoltre materiale ecogeno ostruente è stato osservato a livello della giunzione femoro-safena con solo parziale compressibilità con la compressione ecografica. E' stata effettuata un'angio tomografia computerizzata dell'aorta che ha evidenziato un'ampia trombosi dell'aorta sotto-renale. Il paziente moriva, nonostante la diagnosi in tempi relativamente brevi, mettendo in evidenza l...

Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are polysubstance overdose deaths. And since many of the substances involved in a polysubstance Overdose Death (POD) are Central Nervous System (CNS) depressants, many of which can cause overdose death themselves, or synergistically with opioids, it is somewhat puzzling that prescription opioids have been singled out as the cause of these deaths-without reference to PSA. This is particularly puzzling in light of the fact that the issues of PSA and POD have been recognized and discussed in the literature since at least the 1960's and before. We therefore here consider the question: are we facing an "opioid" crisis or, instead, a "polysubstance crisis"? And we wonder if the issue has been oversimplified , to the detriment of the individuals affected, and to society more broadly. There is a need for an "agnostic" respiratory stimulant that can reverse polysubstance-induced respiratory depression.