Podcast # 425: Oseltamivir Efficacy in Children

Author: Aaron Lessen, MD

Educational Pearls:

  • Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza
  • Those with suspected influenza unsurprisingly had less effect
  • Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset
  • Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk of otitis media

Editor’s note:  Vomiting was higher in the treatment groups; There were no significantly different outcomes in regards to other endpoints, such as lower respiratory tract infections and hospitalizations

References:

Malosh RE, Martin ET, Heikkinen T, Brooks WA, Whitley RJ, Monto AS. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018 May 2;66(10):1492-1500. doi: 10.1093/cid/cix1040. PubMed PMID: 29186364.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 422: ED Opioid Prescription Trends

Author: Jared Scott, MD

Educational Pearls:

 

  • From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain
  • Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64%
  • The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but
  • Total opioids prescribed from the ED still increased 219% over this same time frame

 

References:

Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018 Jun;71(6):659-667.e3. doi: 10.1016/j.annemergmed.2017.12.007. Epub 2018 Jan 16. PubMed PMID: 29373155

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 421: Sweet DKA Pearls

Author: Gretchen Hinson, MD

Educational Pearls:

  • Diabetic ketoacidosis patients are subject to electrolyte derangements
  • Potassium should be monitored closely:
    • K < 3.3 = Do not give insulin and replete K first
    • 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF
    • K > 5.3 = delay potassium replacement
  • Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
  • Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

 

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 419: Etripamil

Author: Don Stader, MD

Educational Pearls:

 

  • Etripamil is an intranasal calcium channel blocker in development for use in SVT
  • A recent study showed that etripamil has an SVT conversion rate of around 80%
  • Etripamil does not have the same feeling of “impending doom” that can occur with adenosine

Editor’s note: Etripamil is still in development and these results are from a phase II clinical trial.

 

References:

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O’Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 416: Wide Complex Tachycardia

Author: Aaron Lessen, MD

Educational Pearls:

  • Defined as QRS over 120 ms and rate over 120
  • Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy
  • Safest approach is to assume it is VT
  • Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy
  • Procainamide is preferred pharmacologic option
  • Amiodarone is less preferred third option
  • Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided

References:

Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 415: Myofascial Pain Syndrome & Fibromyalgia

Author: Ryan Circh, MD

Educational Pearls:

  • Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain
  • Often secondary to repeated use and poor posture.
  • MFPS typically responds very well to trigger point injections.
  • Fibromyalgia is bilateral and diffuse and is thought to have a psychological component
  • Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril

References:

Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004 Feb 15;51(1):9-13. PubMed PMID: 14872449.

Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. Review. PubMed PMID: 15547167.

Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Review. PubMed PMID: 22094195.

Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17. Review. PubMed PMID: 24787338

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast #408: Go the hell to sleep

Author: Don Stader, MD

Educational Pearls:

  • Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient
  • If you have access, ketamine intravenous is the fastest
  • Olanzapine should be used with caution in elderly patients because of its anticholinergic properties
  • Ketamine can transiently worsen psychosis in some mental illness
  • Haloperidol is contraindicated in patients with prolonged QT
  • Olanzapine can be safely given intravenous as another option to your sedating arsenal

References:

Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904.

Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430.

Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

 

 

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Podcast #406: PO vs. IV Tylenol

Author: Don Stader, MD

Educational Pearls:

 

  • Intravenous Tylenol currently is many times more expensive than oral
  • Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control
  • Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action

 

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm. 2015 May-Jun;68(3):238-47. Review. PubMed PMID: 26157186; PubMed Central PMCID: PMC4485512.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast #395: Aspirin for everyone!

Author: Aaron Lessen, MD

Educational Pearls:

  • In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly
  • These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly
  • These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspirin without clear indications

Editor’s note: the increased all cause mortality is intriguing – but attributed to an increase in cancer mortality. Unclear why but will be important to see if this trend is seen in other studies.

 

References:

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PubMed PMID: 30221596.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518. doi: 10.1056/NEJMoa1805819. Epub 2018 Sep 16. PubMed PMID: 30221597.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PubMed PMID: 30221595.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, M

Podcast # 390: Haloperidol for Pain

Author: Gretchen Hinson, MD

Educational Pearls:

  • Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once.
  • Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential.
  • Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that may do so.

Editor’s note: Interested in more alternatives to opioids? Check out the Colorado ACEP Opioid Prescribing & Treatment Guidelines and the impact these have had in Colorado

References:

http://ercast.libsyn.com/haloperidol-for-analgesia

Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118-1120. doi: 10.1016/j.ajem.2017.03.015. Epub 2017 Mar 12. PubMed PMID: 28320545.

Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844. doi: 10.1002/14651858.CD004844.pub3. Review. PubMed PMID: 23990266.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD.