Four hours after the patient's admission to the emergency department her rectal temperature was 35.5O and she was conversing. By this time she had received 5000 mL or warm saline and 500 mL of warm blood. The hemoglobin value in a blood sample taken after 2 L of saline had been given was 9.0 g/dL. Peritoneal lavage was positive and she was taken to the operating room, but laparotomy was essentially negative except for a retroperitoneal hematoma. At that time repair of an open fracture of the left ankle revealed a lacerated posterior tibial artery and vein. Discussion
Most reported survivors of severe hypothermia have a temperature of 250C or greater. I found only one reported case in which the patient survived after having a temperature less than that of my patient.1 That patient, who had a rectal temperature of less than 200C, was resuscitated by means of partial bypass with a heart-lung machine and heat exchanger. The case I have reported was unique in several aspects. The patient's core temperature was below that usually regarded as compatible with survival, and no significant arrhythmia occurred when she was rewarmed. Finally, active rewarming was simple and safe in comparison with other recommended methods. Rewarming methods have been described in past issues of the Journal. Hunt's article2 described surface rewarming in a 5-year-old boy with a rectal temperature of 27 0C by immersion in a hot bath. "Core" rewarming as "the standard.., treatment in many areas.. was discussed in a subsequent letter to the editor by Sereda.3 Methods of core rewarming mentioned were hemodialysis, intrathoracic irrigation with warm solutions, cardiopulmonary bypass, and heated humidification of inspired gases. Hunt pointed out in reply that "the equipment used for rewarming must be readily available and a bathtub is such an item of equipment".4 Equipment and expertise necessary for core rewarming by the methods mentioned is often not immediately available in many Canadian hospitals. All the methods outlined may have complications even in competent hands. Nevertheless, some form of rapid core rewarming is theoretically superior to immersion in a hot bath. Surface rewarming produces initial vasodilatation and return to the heart of cold, acidotic blood from the periphery. This often results in paradoxical cooling that is, a decrease in core temperature as the body is rewarmed externally that is not seen with core rewarming.
Similarly, paradoxically increased acidosis, with its risk of ventricular fibrillation, is avoided with core rewarming. The cardiac output is increased as vasodilatation occurs with core rewarming, and "rewarming shock" is less likely than with surface rewarming. Finally, surface rewarming increases the metabolic needs of the peripheral tissues before increasing tissue perfusion, whereas the opposite is true with core rewarming, so that subsequent tissue loss should be less with core rewarming. My patient had severe hypothermia, which was treated with the equipment and expertise readily available in most Canadian hospitals. Necessary equipment consisted of two intravenous lines (preferably centrally placed), fluids warmed by blood warmers, and a rewarming blanket applied from neck to groin. With this method the problems associated with surface rewarming and the possible complications of the other methods of rewarming were avoided. V. WOOD, MD Emergency physician Vancouver General Hospital Vanconver, BC
References 1. wICKSTROM P, Ruiz E, LILJA GP, Ct al: Accidental hypothermia. Core rewarming with partial bypass. Am J Surg 131: 622, 1976 2. HUNT PK: Effect and treatment of the "diving reflex". Can Med Assoc J 111: 1330, 1974 3. SEREDA WM: Treatment of hypothermia (C). Can Med Assoc J 112: 931, 1975 4. HUNT PK: Treatment of hypothermia (C). Ibid
Unusual therapeutic effect of amitriptyline To the editor: Amitri.tyline had an unusual therapeutic effect in two patients in their early SOs, a man and a woman, referred to me because of depressive symptoms. Each had a compulsive personality, and their first episode of depressive illness was characterized by lack of energy, anorexia and insomnia, among other features. Both complained of loneliness and boredom in their marital situations and resentment of their spouses, who were indifferent to them. Because in both cases the spouses would not consider a joint interview and the symptoms were compatible with psychotic depressive reactions, outpatient treatment with 75 mg of amitriptyline (Elavil) at bedtime was begun. Both patients called the next day to report severe side effects. They were each experiencing dizziness, tachycardia and weakness, as well as other minor side effects frequently reported with amitriptyline. However, they were also fearful of losing control and going crazy, and were overwhelmed by feelings of hatred of their spouses. As one
patient stated, "I became aware of a hatred for him that I had never known existed within me." Both patients discontinued the medication at this time and said they had found the experience terrifying. After 2 weeks both were free of depressive symptoms and had insight into the feelings underlying their depressions. Thereafter their clinical improvement was maintained. Although they were reluctant to take the medication again, both attributed their improvement to the insights into their aggression that they acquired after the first dose. To my knowledge this cathartic effect of a single 75-mg dose of amitriptyline at bedtime has not been reported. Although it is obviously a toxic side effect, I am interested to know if other clinicians have had similar experiences with this drug in this particular type of patient. E.M. WARING, MD, D PSYCH, FRCP[cJ Consultant psychiatrist Victoria Hospital London, Ont.
Correct use of aerosol inhalers To the editor: We were interested to read the recent editorial by J.R. Grainger entitled "Correct use of aerosol inhalers" (Can Med Assoc 1 116: 584, 1977). The discussion of principles of the design and use of an aerosol inhaler is most informative. We are encouraged by the emphasis that physicians and pharmacists should consider poor administration technique one of the major factors contributing to treatment failure with inhaled bronchodilators. We cannot agree, however, with the recommendation that, following full exhalation, the patient "form an airtight seal between the lips and the mouthpiece of the inhaler". We believe that patients should be instructed to keep the mouth open during inhalation (in contrast to the written instructions and photographs that accompany some nebulizers). The tip of the mouthpiece should be positioned about 3 cm from the lips, and the bolus (one puff) inhaled through a widely open mouth during maximal inhalation. Results from studies in animals and humans suggest that only about 10% of an aerosol dose reaches the lungs and that the remainder is either swallowed or exhaled.1 Close attention to technique could reduce the amount of drug that is swallowed by reducing the deposition of particles in the oral cavity during inhalation and exhalation.2 Efforts to reduce systemic absorption after aerosol administration of salbutamol would minimize the development
CMA JOURNAL/JULY 9, 1977/VOL. 117 21
of bothersome side effects such as tachycardia and tremor. Bronchodilation after aerosol administration is due to local deposition of salbutamol on the lungs and is not related to blood concentrations. Butler2 has recommended that patients with side effects be encouraged to wash out their mouths following aerosol administration. We believe that the practice of forming an airtight seal around the mouthpiece of the inhaler contributes to the problem of systemic absorption since a portion of the bolus of particles probably remains in the oral cavity following inspiration. We and others2'4'5 recommend positioning the mouthpiece of the inhaler about 3 cm from the lips and inhaling through a widely open mouth. This technique will draw a stream of air through the mouth, carrying the complete bolus into the airways. Exhalation through the nose is also effective in minimizing the amount of drug that is swallowed. There is a need for greater uniformity in the instructions given to asthmatic patients regarding the use of the hand nebulizer. Standardization of the technique, which is one important aspect of this problem, has not yet been achieved. Realization of this objective is important because (a) it would clear up present confusion surrounding the optimum mode of administration of aerosol bronchodilators, (b) it would ensure that similar instructions are given to patients who see more than one physician, and (c) results of various follow-up trials with patients using hand nebulizers would be not only more meaningful but also more comparable in terms of efficacy and side effects. Finally, we suggest that, by minimizing the deposition of drug particles in the oral cavity, the technique we recommend would permit more drug to enter the airways, with improved clinical response and a lower incidence of untoward effects. Our comments are based solely upon logic and pharmacokinetic considerations; however, controlled clinical trials assessing this aspect of "pocket aerosol" technique would contribute to resolving this issue. We welcome further comments from your readers. C.B. TUTrLE, M SC PHM Supervisor, drug information services Pharmacy department Camp Hill Hospital Halifax, NS J. SIDOROV 4th-year medical student Faculty of medicine Daihousie University Halifax. NS
References 1. DAVIES DS: Pharmacokinetics of inhaled substances. Postgrad Med J Si (suppi 7): 69, 1975 2. Bumaa 3: Eronchodilator treatment of obstructive airway disease. Drug Therapy 3: 69, 76, 77; 1973
3. WALKER SR EVANS ME, RIcIsARDs AJ, et al: The cimicaf pharmacology of oral and inhaled salbutamol. Clin Pharmacol They 13: 861, 1972 4. Osanan J, GAYARD P. GRIMAUD CH, Ct al: Patient error in use of bronchodilator metered aerosols. Br Med 1 1: 76, 1976 5. PAIN MCF: The treatment of asthma. Drugs 6: 118, 1973
To the editor: While the "open-mouth" method is now supported by a number of investigators, to date most studies have been carried out with the lips forming an airtight seal around the mouthpiece of the inhaler. From the beginning it was considered that the space between the actuator wall and the pressurized canister provided an adequate amount of air to assist passage of the drug to its "target", the respiratory tract. With both methods it is vital to inhale deeply and slowly with the aerosol actuated immediately after inhalation begins - that is, timing release of the drug with the start of inspiration. This provides a "supporting" air stream with deep inhalation that carries the drug as far as possible into the respiratory tract; slow inhalation reduces the deposition of larger drug particles in the upper areas of the lung. Finally, it is important to instruct the patient to tilt the head back slightly to form as straight a channel as possible for the inhaled medication, to hold the breath for at least 10 seconds after deep, slow inhalation, then to exhale through the nose. Even when the physician is assured these instructions are being followed, these studies have shown that regular checking of the patient's technique is the only way to ensure continuing benefits. Studies of the most efficient method of delivering microdoses of drugs to the lungs by pressurized aerosol are continuing, but these principles of correct use are unlikely to change. J.R. GRAINGER General manager Allen & Hanburys Barclay Ave. Toronto, Ont.
Leaders haven't learned lessons of history To the editor: It is irritating to find that the most important space in my Journal has been given to the federal minister of health to poke his finger at me telling me how to reduce health care costs (Can Med Assoc J 116:1040, 1977). It astounds me that our so-called leaders have utterly failed to learn the lessons of history with regard to health care costs - that is, if you provide free service to the public, that service will be used a lot, and, if the public is to receive high-standard health care, that is going to cost a lot.
22 CMA JOURNAL/JULY 9, 1977/VOL 117
Depo-Medrol a reflection of your confidence since 1957 Indications and Dosage Intramuscular: Allergic conditions (pollinosis, asthma, rhinitis, drug reactions).80-120 mg If necessary, repeat injection in 1 to 3 weeks. Allergic dermatologic conditions.. 80-120 mg If necessary, repeat injection in 1 to 3 weeks. Rheumatoid arthritis.40-120 mg If necessary, repeat injection in 1 to 5 weeks. Intra-artlcular - Rheumatoid arthritis, osteoarthritis. The dose of Depo-Medrol depends upon the size of the joint and the severity of the condition. Repeated injections, if needed, may be given at intervals of one to five or more weeks depending upon the degree of relief obtained from the initial injection.A suggested dosage guide is: Large joint (knee, ankle, shoulder).20-80 mg Medium joint (elbow, wrist).10-40 mg Small joint (metacarpophalangeal, interphalangeal, sternoclavicular, acromioclavicular).4-10 mg Intrabursal - Subdeltoid bursitis, prepatellar bursitis, olecranon bursitis. For administration directly into bursae.4-30mg In most acute cases, repeat injections are not needed. Into the tendon sheath -Tendinitis, tenosynovitis.4-30 mg Intralesionally - Following cleansing with an appropriate antiseptic such as 70% alcohol, 20 to 60 mg is injected into the lesion. It may be necessary to distribute the dose (ranging frdm 20 to 40 mg) by repeated local injections in the case of large lesions. Cautions: The usual precautions and contraindications to systemic and local steroid therapy should be observed. Intramuscular injections should be made deeply into the gluteal muscles. Intrasynovial injections should be carefully made using precise anatomical localization. Particular care should be given to avoiding major nerves and blood vessels. The usual technique of aspirating prior to injection should be employed to avoid intravascular administration. Do not administer doses recommended for intramuscular administration superficially or subcutaneously. Depo-Medrol with lidocaine should not be administered intravenously or intrathecally and should not be used in patients with a history suggestive of allergy to any local anaesthetic. Intraarticular and intrabursal injections and injections into the tendon sheath are contraindicated in the presence of acute infectious conditions. Detailed information is available on request. Supplied: As methyiprednisolone acetate, 20 mg/mi in 1 ml and 5 ml vials; 40 mg/mI in 1 ml, 2 ml, and 5 ml vials; 80 mg/mI in 1 ml and 5 ml vials.
Also available Depo-Medrol with lidocaine Supplied: As 40 mg/mI methylprednisolone acetate and 10 mg/mI lidocaine hydrochloride in 1 ml, 2 ml, and 5 ml vials. References: 1. Miller, J. (1971). CurrTher. Res.,13:laS. 2. Dubois. E.L. (March 1958). Symposium: Newer Hydrocortisone Analogs, p. 509. 3. Bain, L.S .,et al. (1967). Annals of Phys. Med.,9:49. 4. Lewin, R.A. (1968). Brit. J. Olin. Pract., 22:203. 741
REGI5TEREDTRADEMARK MEDROL TRADEMARK DEPO CE7365.2 MEMBER
-
EE.
THE UPJOHN COMPANY OF CANADA 865 YORK MILLS ROAD/DON MILLS. ONTARIO
Most reported survivors of severe hypothermia have a temperature of 250C or greater. I found only one reported case in which the patient survived after having a temperature less than that of my patient.1 That patient, who had a rectal temperature of less than 200C, was resuscitated by means of partial bypass with a heart-lung machine and heat exchanger. The case I have reported was unique in several aspects. The patient's core temperature was below that usually regarded as compatible with survival, and no significant arrhythmia occurred when she was rewarmed. Finally, active rewarming was simple and safe in comparison with other recommended methods. Rewarming methods have been described in past issues of the Journal. Hunt's article2 described surface rewarming in a 5-year-old boy with a rectal temperature of 27 0C by immersion in a hot bath. "Core" rewarming as "the standard.., treatment in many areas.. was discussed in a subsequent letter to the editor by Sereda.3 Methods of core rewarming mentioned were hemodialysis, intrathoracic irrigation with warm solutions, cardiopulmonary bypass, and heated humidification of inspired gases. Hunt pointed out in reply that "the equipment used for rewarming must be readily available and a bathtub is such an item of equipment".4 Equipment and expertise necessary for core rewarming by the methods mentioned is often not immediately available in many Canadian hospitals. All the methods outlined may have complications even in competent hands. Nevertheless, some form of rapid core rewarming is theoretically superior to immersion in a hot bath. Surface rewarming produces initial vasodilatation and return to the heart of cold, acidotic blood from the periphery. This often results in paradoxical cooling that is, a decrease in core temperature as the body is rewarmed externally that is not seen with core rewarming.
Similarly, paradoxically increased acidosis, with its risk of ventricular fibrillation, is avoided with core rewarming. The cardiac output is increased as vasodilatation occurs with core rewarming, and "rewarming shock" is less likely than with surface rewarming. Finally, surface rewarming increases the metabolic needs of the peripheral tissues before increasing tissue perfusion, whereas the opposite is true with core rewarming, so that subsequent tissue loss should be less with core rewarming. My patient had severe hypothermia, which was treated with the equipment and expertise readily available in most Canadian hospitals. Necessary equipment consisted of two intravenous lines (preferably centrally placed), fluids warmed by blood warmers, and a rewarming blanket applied from neck to groin. With this method the problems associated with surface rewarming and the possible complications of the other methods of rewarming were avoided. V. WOOD, MD Emergency physician Vancouver General Hospital Vanconver, BC
References 1. wICKSTROM P, Ruiz E, LILJA GP, Ct al: Accidental hypothermia. Core rewarming with partial bypass. Am J Surg 131: 622, 1976 2. HUNT PK: Effect and treatment of the "diving reflex". Can Med Assoc J 111: 1330, 1974 3. SEREDA WM: Treatment of hypothermia (C). Can Med Assoc J 112: 931, 1975 4. HUNT PK: Treatment of hypothermia (C). Ibid
Unusual therapeutic effect of amitriptyline To the editor: Amitri.tyline had an unusual therapeutic effect in two patients in their early SOs, a man and a woman, referred to me because of depressive symptoms. Each had a compulsive personality, and their first episode of depressive illness was characterized by lack of energy, anorexia and insomnia, among other features. Both complained of loneliness and boredom in their marital situations and resentment of their spouses, who were indifferent to them. Because in both cases the spouses would not consider a joint interview and the symptoms were compatible with psychotic depressive reactions, outpatient treatment with 75 mg of amitriptyline (Elavil) at bedtime was begun. Both patients called the next day to report severe side effects. They were each experiencing dizziness, tachycardia and weakness, as well as other minor side effects frequently reported with amitriptyline. However, they were also fearful of losing control and going crazy, and were overwhelmed by feelings of hatred of their spouses. As one
patient stated, "I became aware of a hatred for him that I had never known existed within me." Both patients discontinued the medication at this time and said they had found the experience terrifying. After 2 weeks both were free of depressive symptoms and had insight into the feelings underlying their depressions. Thereafter their clinical improvement was maintained. Although they were reluctant to take the medication again, both attributed their improvement to the insights into their aggression that they acquired after the first dose. To my knowledge this cathartic effect of a single 75-mg dose of amitriptyline at bedtime has not been reported. Although it is obviously a toxic side effect, I am interested to know if other clinicians have had similar experiences with this drug in this particular type of patient. E.M. WARING, MD, D PSYCH, FRCP[cJ Consultant psychiatrist Victoria Hospital London, Ont.
Correct use of aerosol inhalers To the editor: We were interested to read the recent editorial by J.R. Grainger entitled "Correct use of aerosol inhalers" (Can Med Assoc 1 116: 584, 1977). The discussion of principles of the design and use of an aerosol inhaler is most informative. We are encouraged by the emphasis that physicians and pharmacists should consider poor administration technique one of the major factors contributing to treatment failure with inhaled bronchodilators. We cannot agree, however, with the recommendation that, following full exhalation, the patient "form an airtight seal between the lips and the mouthpiece of the inhaler". We believe that patients should be instructed to keep the mouth open during inhalation (in contrast to the written instructions and photographs that accompany some nebulizers). The tip of the mouthpiece should be positioned about 3 cm from the lips, and the bolus (one puff) inhaled through a widely open mouth during maximal inhalation. Results from studies in animals and humans suggest that only about 10% of an aerosol dose reaches the lungs and that the remainder is either swallowed or exhaled.1 Close attention to technique could reduce the amount of drug that is swallowed by reducing the deposition of particles in the oral cavity during inhalation and exhalation.2 Efforts to reduce systemic absorption after aerosol administration of salbutamol would minimize the development
CMA JOURNAL/JULY 9, 1977/VOL. 117 21
of bothersome side effects such as tachycardia and tremor. Bronchodilation after aerosol administration is due to local deposition of salbutamol on the lungs and is not related to blood concentrations. Butler2 has recommended that patients with side effects be encouraged to wash out their mouths following aerosol administration. We believe that the practice of forming an airtight seal around the mouthpiece of the inhaler contributes to the problem of systemic absorption since a portion of the bolus of particles probably remains in the oral cavity following inspiration. We and others2'4'5 recommend positioning the mouthpiece of the inhaler about 3 cm from the lips and inhaling through a widely open mouth. This technique will draw a stream of air through the mouth, carrying the complete bolus into the airways. Exhalation through the nose is also effective in minimizing the amount of drug that is swallowed. There is a need for greater uniformity in the instructions given to asthmatic patients regarding the use of the hand nebulizer. Standardization of the technique, which is one important aspect of this problem, has not yet been achieved. Realization of this objective is important because (a) it would clear up present confusion surrounding the optimum mode of administration of aerosol bronchodilators, (b) it would ensure that similar instructions are given to patients who see more than one physician, and (c) results of various follow-up trials with patients using hand nebulizers would be not only more meaningful but also more comparable in terms of efficacy and side effects. Finally, we suggest that, by minimizing the deposition of drug particles in the oral cavity, the technique we recommend would permit more drug to enter the airways, with improved clinical response and a lower incidence of untoward effects. Our comments are based solely upon logic and pharmacokinetic considerations; however, controlled clinical trials assessing this aspect of "pocket aerosol" technique would contribute to resolving this issue. We welcome further comments from your readers. C.B. TUTrLE, M SC PHM Supervisor, drug information services Pharmacy department Camp Hill Hospital Halifax, NS J. SIDOROV 4th-year medical student Faculty of medicine Daihousie University Halifax. NS
References 1. DAVIES DS: Pharmacokinetics of inhaled substances. Postgrad Med J Si (suppi 7): 69, 1975 2. Bumaa 3: Eronchodilator treatment of obstructive airway disease. Drug Therapy 3: 69, 76, 77; 1973
3. WALKER SR EVANS ME, RIcIsARDs AJ, et al: The cimicaf pharmacology of oral and inhaled salbutamol. Clin Pharmacol They 13: 861, 1972 4. Osanan J, GAYARD P. GRIMAUD CH, Ct al: Patient error in use of bronchodilator metered aerosols. Br Med 1 1: 76, 1976 5. PAIN MCF: The treatment of asthma. Drugs 6: 118, 1973
To the editor: While the "open-mouth" method is now supported by a number of investigators, to date most studies have been carried out with the lips forming an airtight seal around the mouthpiece of the inhaler. From the beginning it was considered that the space between the actuator wall and the pressurized canister provided an adequate amount of air to assist passage of the drug to its "target", the respiratory tract. With both methods it is vital to inhale deeply and slowly with the aerosol actuated immediately after inhalation begins - that is, timing release of the drug with the start of inspiration. This provides a "supporting" air stream with deep inhalation that carries the drug as far as possible into the respiratory tract; slow inhalation reduces the deposition of larger drug particles in the upper areas of the lung. Finally, it is important to instruct the patient to tilt the head back slightly to form as straight a channel as possible for the inhaled medication, to hold the breath for at least 10 seconds after deep, slow inhalation, then to exhale through the nose. Even when the physician is assured these instructions are being followed, these studies have shown that regular checking of the patient's technique is the only way to ensure continuing benefits. Studies of the most efficient method of delivering microdoses of drugs to the lungs by pressurized aerosol are continuing, but these principles of correct use are unlikely to change. J.R. GRAINGER General manager Allen & Hanburys Barclay Ave. Toronto, Ont.
Leaders haven't learned lessons of history To the editor: It is irritating to find that the most important space in my Journal has been given to the federal minister of health to poke his finger at me telling me how to reduce health care costs (Can Med Assoc J 116:1040, 1977). It astounds me that our so-called leaders have utterly failed to learn the lessons of history with regard to health care costs - that is, if you provide free service to the public, that service will be used a lot, and, if the public is to receive high-standard health care, that is going to cost a lot.
22 CMA JOURNAL/JULY 9, 1977/VOL 117
Depo-Medrol a reflection of your confidence since 1957 Indications and Dosage Intramuscular: Allergic conditions (pollinosis, asthma, rhinitis, drug reactions).80-120 mg If necessary, repeat injection in 1 to 3 weeks. Allergic dermatologic conditions.. 80-120 mg If necessary, repeat injection in 1 to 3 weeks. Rheumatoid arthritis.40-120 mg If necessary, repeat injection in 1 to 5 weeks. Intra-artlcular - Rheumatoid arthritis, osteoarthritis. The dose of Depo-Medrol depends upon the size of the joint and the severity of the condition. Repeated injections, if needed, may be given at intervals of one to five or more weeks depending upon the degree of relief obtained from the initial injection.A suggested dosage guide is: Large joint (knee, ankle, shoulder).20-80 mg Medium joint (elbow, wrist).10-40 mg Small joint (metacarpophalangeal, interphalangeal, sternoclavicular, acromioclavicular).4-10 mg Intrabursal - Subdeltoid bursitis, prepatellar bursitis, olecranon bursitis. For administration directly into bursae.4-30mg In most acute cases, repeat injections are not needed. Into the tendon sheath -Tendinitis, tenosynovitis.4-30 mg Intralesionally - Following cleansing with an appropriate antiseptic such as 70% alcohol, 20 to 60 mg is injected into the lesion. It may be necessary to distribute the dose (ranging frdm 20 to 40 mg) by repeated local injections in the case of large lesions. Cautions: The usual precautions and contraindications to systemic and local steroid therapy should be observed. Intramuscular injections should be made deeply into the gluteal muscles. Intrasynovial injections should be carefully made using precise anatomical localization. Particular care should be given to avoiding major nerves and blood vessels. The usual technique of aspirating prior to injection should be employed to avoid intravascular administration. Do not administer doses recommended for intramuscular administration superficially or subcutaneously. Depo-Medrol with lidocaine should not be administered intravenously or intrathecally and should not be used in patients with a history suggestive of allergy to any local anaesthetic. Intraarticular and intrabursal injections and injections into the tendon sheath are contraindicated in the presence of acute infectious conditions. Detailed information is available on request. Supplied: As methyiprednisolone acetate, 20 mg/mi in 1 ml and 5 ml vials; 40 mg/mI in 1 ml, 2 ml, and 5 ml vials; 80 mg/mI in 1 ml and 5 ml vials.
Also available Depo-Medrol with lidocaine Supplied: As 40 mg/mI methylprednisolone acetate and 10 mg/mI lidocaine hydrochloride in 1 ml, 2 ml, and 5 ml vials. References: 1. Miller, J. (1971). CurrTher. Res.,13:laS. 2. Dubois. E.L. (March 1958). Symposium: Newer Hydrocortisone Analogs, p. 509. 3. Bain, L.S .,et al. (1967). Annals of Phys. Med.,9:49. 4. Lewin, R.A. (1968). Brit. J. Olin. Pract., 22:203. 741
REGI5TEREDTRADEMARK MEDROL TRADEMARK DEPO CE7365.2 MEMBER
-
EE.
THE UPJOHN COMPANY OF CANADA 865 YORK MILLS ROAD/DON MILLS. ONTARIO
