Podcast # 438 : tPA for Frostbite

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Several studies have shown administration of tPA can improve outcomes and reduce need for amputation
  • tPA is considered in grade III and IV frostbite
  • tPA cannot be given until after the warming process
  • Administration is systemically, not catheter directed or intra-arterial

References:

Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671.

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

Podcast # 436 : Epinephrine Autoinjectors

Author: Charleen Gnisci, PharmD

Educational Pearls:

 

  • Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs)
  • AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently
  • Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease

 

References:

Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html.

Tirrell, M.  FDA approves Teva’s generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html

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

Podcast # 433: Geriatric Ketamine

Author: Michael Hunt, MD

Educational Pearls:

  • Recent study compared ketamine to morphine in elderly patient
  • Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine  (IV dose 0.1 mg / kg)
  • However, etamine group had much higher rate of side effects, including psychoperceptual
  • A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population – you can always add more! 

References

Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629.

 Summarized and edited by Erik Verzemnieks, MD

Podcast # 431: Medication Errors

Author: Rachel Brady, MD

Educational Pearls:

  • Medication errors are estimated to be the 3rd leading cause of death
  • A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death
  • About 50% are in the ordering/prescribing phase; 25-30% during administration phase.
  • Overworked and distracted providers are the most common underlying reasons for medication error
  • A 2017 study found 40% of ED nurses witnessed a medication error in the last year

Editor’s Note:  This is a reasonable counterpoint

References

Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712.

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499.

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

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, Mond√©sert 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

Check out this episode!

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

Check out this episode!

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

Check out this episode!