should male patients with chest pain be questioned about viagra use during triage screening?

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8 JOURNAL OF EMERGENCY NURSING 27:1 February 2001 LETTERS causes a positive benzodiazepine result on urine toxicology screens and seems to emulate the effects of this drug class in terms of clinical manifestation, one would query whether flumazenil (Romazicon) has any role in the rever- sal of the acute toxidrome associated with the drug. I have been unable to find any mention of this possibility in orga- nized published studies or even anecdotal reports of its use in discussion with local emergency physicians, toxicology specialists, and nursing colleagues. Published data do sug- gest that the drug acts similarly to benzodiazepines at both the limbic and subcortical levels of the central nervous sys- tem (thus the profound altered mentation and depressed level of consciousness associated with nearly total antero- grade amnesia following the onset of action, which explains the drug’s popularity as a “date rape” drug). Additionally, it has been suggested in several articles that the drug’s effects result from its binding at specific recep- tors in the central nervous system and because it enhances the inhibitory tone of gamma-aminobenzoic acid (GABA) receptors. It would seem logical that a competitive benzo- diazepine antagonist (ie, flumazenil) may have some bene- fit in the rapid reversal of life-threatening complications (seizure, coma, respiratory depression/apnea and acidosis, profound bradycardia, and aspiration) of acute GHB toxi- city. Conversely, one could also infer the possibility of sta- tus seizures and central nervous system irritability resulting from rapid reversal. Clearly more research and public edu- cation efforts need to be focused in this area because the number of acute GHB intoxications is rising rapidly. I would welcome any personal communications or ref- erence to published research in regard to GHB/GBL, as well as any anecdotal experiences in the diagnosis and treat- ment of this pervasive and dangerous “supplement.”—Kurt Gensert, RN, BSN, CEN, Charge Nurse/Clinical Nurse III, Emergency Department, Platte Valley Medical Center, Brighton, Colo; E-mail: [email protected] 18/64/113248 doi:10.1067/men.2001.113248 Should male patients with chest pain be questioned about Viagra use during triage screening? Dear Editor: We recently cared for a 41-year-old man with chest pain that he had had intermittently throughout the day. He had seen his primary care provider earlier in the day; an EKG was done in the office and was read as normal. The patient had multiple cardiac risk factors, both medical and social. His initial EKG in the emergency department showed anterior wall ST segment elevations with recipro- cal changes. He was given a sublingual Nitro 1/150 (his blood pressure was 190/100). Within minutes, he went into a pulseless VT, which responded to a single defibrilla- tion at 200 J. He converted into a controlled rate atrial fib- rillation and awoke almost pain free. Subsequent EKGs (Nos. 2 and 3) showed worsening ST segment elevations in the anterior leads. Further ques- tioning of the patient revealed that he had taken 100 mg of sildenafil citrate (Viagra) 2 hours before coming to the emergency department. This information was not divulged during the initial triage. A fourth EKG done 20 minutes after the VT arrest showed almost complete resolution of the ST segment elevations. A cardiologist was consulted, and the decision was made not to administer thrombolyt- ics. The next day the patient was transferred to a nearby hospital for cardiac catheterization, which was positive for an 80% to 90% occlusion of the left anterior descending artery. The time frame for use of nitrates after ingestion of Viagra is unclear. A waiting period of 24 hours is suggest- ed. 1 All patients taking nitrates should be made aware of the potentially life-threatening vasodilatation and hypotension that can occur when nitrates are combined with Viagra. Viagra is contraindicated for patients taking any form of nitrate medication, whether short-acting or long-acting. 1,2 Viagra was approved for use by the Food and Drug Administration on March 27, 1998. Marketing reports from Pfizer, Inc, indicate that more than 6 million outpa- tient prescriptions (representing 50 million tablets) were dispensed between late March and mid November 1998. 3,4 Approximately 5.5 million men take nitrates on a regular basis for angina, and another .5 million become potential candidates yearly. Viagra is potentially contraindicated in as many as 6 million men. 1,3 Viagra is not a medication we typically encounter in emergency medicine. Our major concern with Viagra is its potentially lethal effect when combined with any form of nitrate therapy. Unfortunately, many ED patients are poor

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Page 1: Should male patients with chest pain be questioned about Viagra use during triage screening?

8 JOURNAL OF EMERGENCY NURSING 27:1 February 2001

LETTERS

causes a positive benzodiazepine result on urine toxicologyscreens and seems to emulate the effects of this drug classin terms of clinical manifestation, one would querywhether flumazenil (Romazicon) has any role in the rever-sal of the acute toxidrome associated with the drug. I havebeen unable to find any mention of this possibility in orga-nized published studies or even anecdotal reports of its usein discussion with local emergency physicians, toxicologyspecialists, and nursing colleagues. Published data do sug-gest that the drug acts similarly to benzodiazepines at boththe limbic and subcortical levels of the central nervous sys-tem (thus the profound altered mentation and depressedlevel of consciousness associated with nearly total antero-grade amnesia following the onset of action, whichexplains the drug’s popularity as a “date rape” drug).Additionally, it has been suggested in several articles thatthe drug’s effects result from its binding at specific recep-tors in the central nervous system and because it enhancesthe inhibitory tone of gamma-aminobenzoic acid (GABA)receptors. It would seem logical that a competitive benzo-diazepine antagonist (ie, flumazenil) may have some bene-fit in the rapid reversal of life-threatening complications(seizure, coma, respiratory depression/apnea and acidosis,profound bradycardia, and aspiration) of acute GHB toxi-city. Conversely, one could also infer the possibility of sta-tus seizures and central nervous system irritability resultingfrom rapid reversal. Clearly more research and public edu-cation efforts need to be focused in this area because thenumber of acute GHB intoxications is rising rapidly.

I would welcome any personal communications or ref-erence to published research in regard to GHB/GBL, aswell as any anecdotal experiences in the diagnosis and treat-ment of this pervasive and dangerous “supplement.”—KurtGensert, RN, BSN, CEN, Charge Nurse/Clinical Nurse III,Emergency Department, Platte Valley Medical Center,Brighton, Colo; E-mail: [email protected]

18/64/113248doi:10.1067/men.2001.113248

Should male patients with chest pain be questioned aboutViagra use during triage screening?

Dear Editor:We recently cared for a 41-year-old man with chest

pain that he had had intermittently throughout the day.

He had seen his primary care provider earlier in the day; anEKG was done in the office and was read as normal. Thepatient had multiple cardiac risk factors, both medical andsocial. His initial EKG in the emergency departmentshowed anterior wall ST segment elevations with recipro-cal changes. He was given a sublingual Nitro 1/150 (hisblood pressure was 190/100). Within minutes, he wentinto a pulseless VT, which responded to a single defibrilla-tion at 200 J. He converted into a controlled rate atrial fib-rillation and awoke almost pain free.

Subsequent EKGs (Nos. 2 and 3) showed worseningST segment elevations in the anterior leads. Further ques-tioning of the patient revealed that he had taken 100 mg ofsildenafil citrate (Viagra) 2 hours before coming to theemergency department. This information was not divulgedduring the initial triage. A fourth EKG done 20 minutesafter the VT arrest showed almost complete resolution ofthe ST segment elevations. A cardiologist was consulted,and the decision was made not to administer thrombolyt-ics. The next day the patient was transferred to a nearbyhospital for cardiac catheterization, which was positive foran 80% to 90% occlusion of the left anterior descendingartery.

The time frame for use of nitrates after ingestion ofViagra is unclear. A waiting period of 24 hours is suggest-ed.1 All patients taking nitrates should be made aware ofthe potentially life-threatening vasodilatation andhypotension that can occur when nitrates are combinedwith Viagra. Viagra is contraindicated for patients takingany form of nitrate medication, whether short-acting orlong-acting.1,2

Viagra was approved for use by the Food and DrugAdministration on March 27, 1998. Marketing reportsfrom Pfizer, Inc, indicate that more than 6 million outpa-tient prescriptions (representing 50 million tablets) weredispensed between late March and mid November 1998.3,4

Approximately 5.5 million men take nitrates on a regularbasis for angina, and another .5 million become potentialcandidates yearly. Viagra is potentially contraindicated inas many as 6 million men.1,3

Viagra is not a medication we typically encounter inemergency medicine. Our major concern with Viagra is itspotentially lethal effect when combined with any form ofnitrate therapy. Unfortunately, many ED patients are poor

Page 2: Should male patients with chest pain be questioned about Viagra use during triage screening?

February 2001 27:1 JOURNAL OF EMERGENCY NURSING 9

LETTERS

reporters of their health and medication histories. Theymay not understand that even occasional use of a medica-tion needs to be reported. They may be embarrassed toadmit that they use Viagra or lack knowledge about theimportance of reporting the use of Viagra.

After caring for this patient, the following questionarose for our staff: Should a question about Viagra use beincluded in the screening of male patients with chestpain?—Robin Walsh RN, BSN, CEN, CCRN, MercyHospital, Springfield, Mass; E-mail: [email protected]

REFERENCES1. ACC/AHA Expert Consensus Document: Use of sildenafil

(Viagra) in patients with cardiovascular disease. Circulation1999;99:168-77.

2. Pfizer Viagra Package Insert [on-line], 1999. Available at: URL:www.viagra.com/hcp/pro_pack_insert.htm.

3. Clinician Reviews: Summary statement of the American Collegeof Cardiology and the American Heart Association on the use ofsildenafil (Viagra) in patients at clinical risk from cardiovasculareffects [on-line], 1998. Available at: URL: www.medscape.com.

4. Viagra information [on-line]. Available at: URL: www.healthcen-ter. com/pharmacy/.

18/64/113249doi:10.1067/men.2001.113249

More on Mandatory Overtime and Wearing Blue Ribbons

Dear Editor:I would like to thank you for your supportive, com-

prehensive, and eloquent editorial (2000;26:201-2). I havebeen a nurse for 14 years and have worked at St VincentHospital for 8 years. St Vincent’s was a Catholic hospitalwhen I began working there and it was sold, and then soldagain, finally to the second largest for-profit hospital chainin the United States. Over the course of my years at StVincent’s, our benefits began to disappear. Holidays, vaca-tion days, even our paltry charge nurse differential (60cents an hour) were gradually taken away.

What finally forced our call to organize and ultimate-ly strike, however, was dangerously low staffing. Whennurses left, their positions were not re-posted. The num-ber of nurses decreased from 600 to 535. Our patientassignments rose from 5 or 6 patients on the day orevening shift to 9 or 10 patients. We had to prioritizewhich patients would get essentially no care, because oth-ers were sicker. We went to managers and said that wecould not go on; we were dead on our feet, we constantly

believed that we had not done nearly enough for ourpatients, and the situation was dangerous. Managers wereas helpless as we were. Administration said that staffingwas solely at the discretion of management and that nurs-es had nothing to say about it.

It was under this administration that nurses were toldthat they could only issue one blanket per patient becauseblankets weighed more than sheets and cost more to dryin the laundry. If a patient complained of being cold, wewere to give them a double folded sheet. There was a mas-sive outsourcing and contracting of patient services,resulting in 130 people being laid off. Patient services andprograms that did not make a profit were shut down.Supplies and equipment became cheaper and cheaper.Parts of IV sets were incompatible with other parts. Bloodtubing and filters were inferior and clogged easily; as aresult, precious blood was lost that should have gone topatients.

We called the Massachusetts Nurses Association(MNA), asked for help, and began to organize. What fol-lowed was 2 years of dragged-out negotiations in whichnurses made concession after concession in an attempt tocomplete our first contract. Hospital administration saidthat the MNA was using us for “another agenda” that wasnever quite defined. But, in fact, we, the nurses of StVincent, were the union; we were MNA.

The decision to strike was the hardest thing that ourmore than 500 nurses ever had to do. The hospital gave usno choice but to strike, given that they were unmovable intheir position that an unlimited number of forced 16-hourshifts would be required of nurses. Mandatory overtimehad never existed at St Vincent’s before, and nurses hadpowerful feelings about beginning the practice of placingtheir patients, their licenses, and their livelihoods in dan-ger. The strike was authorized by a vote with a 3 to 1 mar-gin, signaling just how powerful those feelings were. Asdifficult as it was to strike and go without our pay andhealth insurance, the difficulty was tempered by thetremendous support we received, literally from around theworld. Electronic communication made a difference, andwe heard from other nurses as far away as Europe andAustralia. Nurses from around the United States joined uson the picket line, and financial contributions came infrom everywhere. At home, our entire community, from