Case Presentation

1
Case Presentation 18
Jim Pointer, MD Alameda County EMS Medical
Director
2
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 having a heart
  attack.

3
Initial Assessment

• Middle-aged Asian male complaining left sided
  chest pain
• ABCs 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 lt 1.0 mg/ml)
• Myocardial Troponin T
• 4.6 mg/ml (normal lt 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 gt 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 1950s due to
  ephedrines 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

20
six-pack for sale
21
The Warning Label!
CONSULT A PHYSICIAN BEFORE PRODUCT USE IF YOU
HAVE, OR HAVE A FAMILY HISTORY OF,THYROID OR
HEART DISEASE, DIABETES, HIGH BLOOD PRESSURE,
RECURRENT HEADACHES, DEPRESSION, ANY PSYCHIATRIC
CONDITION, GLAUCOMA, DIFFICULTY URINATING,
ENLARGED PROSTATE, SEIZURE DISORDER EXCEEDING
RECOMMENDED DOSE OF 100 MG A DAY MAY CAUSE
SERIOUS ADVERSE HEALTH EFFECTS INCLUDING HEART
ATTACK AND STROKE.
READ ENTIRE LABEL WARNING IMMEDIATELY
BELOW.   WARNINGNOT FOR USE BY OR SALE TO
PERSONS UNDER AGE18 DO NOT USE IF PREGNANT OR
NURSING. CONSULT A PHYSICIAN OR LICENSED
QUALIFIED HEALTH CARE PROFESSIONAL ("PHYSICIAN")
BEFORE PRODUCT USE IF YOU HAVE, OR HAVE A FAMILY
HISTORY OF, HEART OR THYROID DISEASE, DIABETES,
HIGH BLOOD PRESSURE, RECURRENT HEADACHES,
DEPRESSION, ANY PSYCHIATRIC CONDITION, GLAUCOMA,
DIFFICULTY URINATING, ENLARGED PROSTATE, SEIZURE
DISORDER, IF YOU ARE USING A MONOAMINE OXIDASE
INHIBITOR (MAOI) OR ANY OTHER DIETARY SUPPLEMENT,
PRESCRIPTION DRUG OR OVER-THE-COUNTER DRUG
CONTAINING EPHEDRINE, PSEUDOEPHEDRINE
OR   PHENYLPROPANOLAMINE (INGREDIENTS FOUND IN
CERTAIN ALLERGY, ASTHMA, COUGH/COLD AND WEIGHT
CONTROL PRODUCTS), OR IF YOU INTEND ON TAKING TO
REDUCE WEIGHT. UNDER LAW, THE MAXIMUM
RECOMMENDED DOSAGE OF EPHEDRINE FOR A HEALTHY
ADULT IS IOOMG IN A 24-HOUR PERIOD FOR NOT MORE
THAN 12 WEEKS. EXCEEDING RECOMMENDED SERVING MAY
CAUSE SERIOUS ADVERSE HEALTH EFFECTS INCLUDING
HEART ATTACK AND STROKE. DISCONTINUE USE AND
CALL A PHYSICIAN IMMEDIATELY IF YOU EXPERIENCE
RAPID HEARTBEAT, DIZZINESS, SEVERE HEADACHE,
SHORTNESS OF BREATH, OR OTHER SIMILAR SYMPTOMS.
INDIVIDUALS WHO CONSUME CAFFEINE WITH THIS
PRODUCT MAY EXPERIENCE SERIOUS ADVERSE HEALTH
EFFECTS. KEEP OUT OF THE REACH OF CHILDREN.
THIS PRODUCT HAS-68 MILLIGRAMS CONCENTRATED
EPHEDRINE GROUP ALKALOIDS PER SERVING IN THE FORM
OF HERBAL EXTRACTS.
22
Side Effects

• Sympathomimetic stimulant

• Uterine contractions
• (contraindicated in
• pregnancy)
• Headaches
• Tremors
• Insomnia
• Restlessness
• Palpitations
• Hallucinations

• Seizures
• Worsening of glaucoma
• Difficulty urinating
• High blood pressure
• Worsening hyperthyroidism
• Myocardial infarction
• Cardiac arrest
• Death

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