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

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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.

Podcast #387: Fluoroquinolones are Perfectly Safe?

Author:  Don Stader, MD

Educational Pearls:

  • Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection.
  • Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%).
  • Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms.
  • Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well.

 

Editor’s note:  In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia

References:

Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.

Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.

https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf

 

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

Podcast # 372: The Latest on Epinephrine in Cardiac Arrest

Author:  Don Stader, MD

Educational Pearls:

  • 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
  • 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
  • Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
  • Adds to literature that epinephrine provides little important benefit in cardiac arrest – focus on chest compressions and early defibrillation

 

Editor’s note: NNT for epinephrine to prevent one death in this study was 115 – compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.

 

References

Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.    N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.

Podcast #357: Local Anesthetic Toxicity

Author: Michael Hunt, MD

Educational Pearls:

  • Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot
  • Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest.
  • Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg.
  • Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg

Editor note: treat seizures with benzodiazepines and avoid propofol for sedation; severe toxicity can also be treated with a 20%  lipid emulsion, though there is debate on its efficacy

References

Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. doi: 10.1177/1090820X14543102.

Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. doi: 10.1097/AAP.0b013e31822e0d8a.

Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern. Reg Anesth Pain Med. 2015 Nov-Dec;40(6):698-705. doi: 10.1097/AAP.0000000000000320.