Category: Pharmacology & Therapeutics
Keywords: low back pain, opioids, naproxen, oxycodone, cyclobenzaprine (PubMed Search)
Posted: 10/21/2015 by Bryan Hayes, PharmD
(Updated: 11/7/2015)
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If there weren't enough reasons to avoid opioids, here is another: opioids don't work for low back pain (LBP).
Objective
A well-done, double-blind, randomized controlled trial from JAMA set out to compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.
Intervention
Outcome
Neither oxycodone/acetaminophen nor cyclobenzaprine improved pain or functional outcomes at 1 week compared to placebo, and more adverse effects were noted.
Application to Clinical Practice
Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, avoid adding opioids or cyclobenzaprine to the standard NSAID therapy.
Friedman BW, et al. Naproxen with Cyclobenzaprine, Oxycodone/Aceaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA 2015;314(15):1572-80.
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Category: Toxicology
Keywords: THC, Spice, JWH (PubMed Search)
Posted: 11/5/2015 by Kathy Prybys, MD
(Updated: 11/6/2015)
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Designer drugs are structural or functional analogs of controlled substances produced to mimic pharmacological effects of the original compound while circumventing legal restrictions and detection on drug screens. Considered "legal highs" by the public, these highly potent drugs are produced in clandestine laboratories with no regulations for quality control or clinical testing for phamacological effects and thus present major threat to public health. Examples include synthetic hallucinogens (DOM: STP), opiates ( methylfentanyl:china white), stimulants (methamphetamine:crank, MDMA: ecstasy, cathinones:bath salts) and synthetic cannabinoids (spice).
The synthetic cannabinoids are the newest designer drugs and numerous cases of intoxication are being reported including some fatalties.Cannabinoids fall into 3 classes: endocannabinoids, phytocannabinoids, synthetic. Marijuana, the best known cannabinoid is plant derived and its psychoactive effects are mainly due to delta-9-tetrahydrocannabinol (THC) which binds with the endocannabinoid receptors CB1 and CB2 found throughout the central and peripheral nervous system and peripheral organs. The CB receptors interact with opiate receptors which is likely responsible for the analgesic effect.
Since 1984, the John Huffman research group at Clemenson University synthesized over 450 cannabinoid compounds for biomedical reseach known as "JWH compounds". These compounds hold great promise in the investigation of multiple diseases and development of new novel therapies. Over the last several years, these cannabinoid compounds began cropping up sprayed onto herbs marketed in colorful packets and sold on the internet, convienence stores, and head shops. Although clearly labeled as "not for human consumption" considered on the street as a legal alternative to marijuana.
Key Points:
Seely KA, Lapoint , et al. Spice drugs are more than harmless herbal blends: a review of pharmacology and toxicology of synthetic cannabinoids. Progress in Neuropharmacology & Biological Psychiatry (2012), doi:10.1016/j.pnpbp.2012.04.017
Wiley JL. Marusich JA. et al. Hijacking of basic research: the case of synthetic cannabinoids. Methods Rep RTI Press. 2011 November; 2011; .doi: 10.3768/rtipress.2011.op.0007.1111
Category: Pediatrics
Keywords: glenohumoral dislocations, anterior shoulder, orthopedics, pediatrics (PubMed Search)
Posted: 11/6/2015 by Kathleen Stephanos, MD
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- Anterior shoulder dislocations often require surgical management in young adults due to recurrence, but are less common in pediatric patients, particularly under age 10
- A study this year showed that 14-16 year olds are similar to 17-20 year olds in recurrence risk (around 38%- when non-operative management), and this is especially true of males.
- The recurrence rate is lower in the 10-13 age group, but there are also less dislocations in this group as well, making this group harder to assess
- Remember to consider both chronologic and bone age if you are deciding to refer a patient for outpatient surgery follow up, bone age is more accurate to determine healing and response to non-operative treatment
- Consider early referral for surgical management and counseling regarding recurrence risk in the 14-16 year age group after anterior shoulder dislocations
Leroux T, et al. The epidemiology of primary anterior shoulder dislocations in patients aged 10-16. Amer J of Sports Med. 2014; 42(2): 442-50.
Category: International EM
Keywords: Sickle Cell Disease, Africa, hemoglobinopathy (PubMed Search)
Posted: 11/4/2015 by Jon Mark Hirshon, PhD, MPH, MD
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Sickle Cell Disease (SCD) is a hemoglobinopathy that is considered a relatively rare disease in the United States, affecting about 90,000-100,000 individuals.
Globally, SCD affects millions, primarily in West and Central Africa.
Acute presentations of SCD include:
The bottom line:
http://www.cdc.gov/ncbddd/sicklecell/data.html
http://www.nhlbi.nih.gov/health/health-topics/topics/sca/signs
http://emedicine.medscape.com/article/205926-clinical
Category: Critical Care
Posted: 11/3/2015 by Mike Winters, MBA, MD
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Pain Management in the Critically Ill Patient
Sigakis MJG, Bittner EA. Ten myths and misconceptions regarding pain management in the ICU. Crit Care Med 2015; 43:2468-2478.
Category: Visual Diagnosis
Posted: 11/1/2015 by Haney Mallemat, MD
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Patient complains of facial and neck swelling, what's the diagnosis?
Subcutaneous emphysema
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Category: Orthopedics
Posted: 10/31/2015 by Michael Bond, MD
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Happy Halloween!!
I hope you have had a safe and fun Halloween. Thank you to all the people that are staffing the EDs on a Saturday Night Halloween.
Prostate-Selective Alpha Antagonists have been tied to Falls and increased risk of fractues in elderly men. These medications can lead to syncope and hypotension putting patients at increased risk of falls. A recent canadian study showed that at 90 days of use; individuals on alpha antagonists were at increased risk of hospital visits for falls (1.45% vs. 1.28%) or fractures (0.48% vs. 0.41%). There was also an increased risk of head trauma.
Please warn patients that are on these medications of the risks, so that injuries can be minimized. They should take specific care when changing postural positions, and report episodes of lightheadedness to their PCPs.
The article can be found at http://www.bmj.com/content/351/bmj.h5398
Category: Airway Management
Keywords: headache, pain (PubMed Search)
Posted: 10/28/2015 by Danya Khoujah, MBBS
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Category: Orthopedics
Keywords: back pain, analgesia (PubMed Search)
Posted: 10/24/2015 by Brian Corwell, MD
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A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).
However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.
This use of this "pain cocktail" is not recommended
Behrbalk E, Halpern P, Boszczyk BM, et al. Anxiolytic medication as an adjunct to morphine analgesia for acute low back pain management in the emergency department: A prospective randomized trial. Spine (Phila Pa 1976). 2014;39(1):17-22.
Category: Pediatrics
Keywords: UTI, Fever, febrile, AAP, clinical practice guideline (PubMed Search)
Posted: 10/23/2015 by Mimi Lu, MD
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Fever is the most common presenting symptoms to pediatric emergency departments 10-20%
Singh S., Sandelich S., Current Status of the Diagnosis and Treatment of Pediatric Urinary Tract Infections. Pediatric Emergency Medicine Reports 2014;19(2):13-22.
Roberts KB, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infactns and children 2 to 24 months. Pediatrics. 2011 Sept; 128(3):595-610.
Category: Toxicology
Keywords: propranolol, lipid emulsion (PubMed Search)
Posted: 10/22/2015 by Fermin Barrueto
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There have been a variety of case reports that have been describing the effects of lipid emulsion therapy on severe hemodynamic overdoses. As time has gone on, we have realized that this therapy is not for all severe overdoses. The type of medication and its pharmacokinetic properties factor into the decision. There is minimal evidence and no ideal randomized control trials that will tell us what the right answer is but take beta-blockers for instance:
Atenolol - in overdose, consider hemodialysis, very effectively removed by HD [1]
Propranolol - very lipophilic and one of the few beta-blockers that can cause widened QRS, seizures as well as the prototypical hypotension and bradycardia.
Because of its lipophilicity, ability to cross the blood brain barrier and ability to cause lethal dysrrthmias, lipid emulsion therapy has been effective in reversing the clinically severe effects of a propranolol overdose. [2]
1)Case report: atenolol overdose successfully treated with hemodialysis.
Huang SH, Tirona RG, Ross C, Suri RS.
Hemodial Int. 2013 Oct;17(4):652-5. doi: 10.1111/hdi.12020. Epub 2013 Jan 24.
Jovic-Stosic J, Gligic B, Putic V, Brajkovic G, Spasic R.
Clin Toxicol (Phila). 2011 Jun;49(5):426-30. doi: 10.3109/15563650.2011.583251.
Category: International EM
Keywords: Road traffic, injuries, World Health Organization (PubMed Search)
Posted: 10/20/2015 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 11/4/2015)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
The World Health Organization (WHO) has just released a report on the current status of road traffic safety globally.
From a postive perspective, road traffic deaths are stabilzing even though the number of motor vehicles are rapidly increasing.
The bottom line- injuries are preventable. Continued policy efforts, laws with enforncement, can save lives. Specific life saving legislation includes:
http://www.who.int/mediacentre/news/releases/2015/road-safety-report/en/
Category: Critical Care
Posted: 10/20/2015 by Haney Mallemat, MD
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There is more than the standard preparations of plasma, platelets, and PRBCs in the blood bank. Certain patients will require these specialized preparations when a transfusion is required. Here are three to know:
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Category: Visual Diagnosis
Posted: 10/19/2015 by Haney Mallemat, MD
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8 year-old female presents with nausea, vomiting, double-vision and inability to move her left eye upwards after being kicked in the face at school. What's the diagnosis?
Orbital floor fracture with entrapment of the inferior rectus muscle.
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Category: Pediatrics
Keywords: Blunt abdominal trauma, seat belt sign, pediatrics (PubMed Search)
Posted: 10/16/2015 by Jenny Guyther, MD
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Our suspicion of significant abdominal injury increases when there is bruising across the abdomen in adults after a motor vehicle collision, but what about in children? A PECRAN analysis may have provided us with the answer.
Of 3740 pediatric patients after motor vehicle collision, 16% had a seat belt sign. Seat belt sign was defined as a continuous area of erythema, ecchymosis or abrasion across the abdomen due to the seat belt. 1864 children had CT scans of the abdomen. Intra-abdominal injuries (IAI) were more common in those children with seat belt sign than those without (19% versus 12%). Those with seat belt sign had a greater risk of hallow viscous or mesenteric injuries. There was no increased risk of solid organ injury. 33% of patients with seat belt sign did not have complaints of abdominal pain or tenderness on initial exam (with a GCS of 14 or 15); 2% of these patients underwent operative intervention for their injuries.
Borgialli et al. Association Between the Seat Belt Sign and Intra-abdominal Injuries in Children With Blunt Torso Trauma in Motor Vehicle Collisions. Academic Emergency Medicine, 2014; 21: 1240 1248.
Category: Toxicology
Keywords: body stuffer, body packer, CAT Scan (PubMed Search)
Posted: 10/15/2015 by Hong Kim, MD
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Toxicity due to body packing and body stuffing can be a significant concern due to unknown quantity and/or substance that was ingested.
A recent prospective observational case series compared the utility of CT abdomen/pelvis with and without PO contrast in identifying the ingested packets.
The gold standard comparison: surgical removal or expulsion of packets.
All patients received CT abd/pelvis with and without PO contrast.
A. Body stuffers (n = 24)
CT w/ PO contrast:
Positive: 7 (sensitivity 29.2%)
Negative: 17
CT w/o PO contrast:
Positive: 9 (sensitivity 36.5%)
Negative: 15
All 24 patients passed ingested packets
B. Body packers (n= 11)
CT w/ PO contrast
CT w/p PO contrast
10 patients expulsed packets; one patient did not have any packets.
Conclusion
Bottom line:
Shahnazi M et al. Comparison of abdominal computed tomography with and without oral contrast in diagnosis of body packers and body stuffers. Clin Toxicol 2015;53:596-603.
Category: Neurology
Keywords: serotonin syndrome, SSRI, SNRI, MAOI, TCA (PubMed Search)
Posted: 10/14/2015 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
Last month we discussed symptoms of serotonin syndrome and its diagnosis by the Hunter Criteria. Let's move on to what causes serotonin syndrome.
Serotonin Syndrome - What Causes It?
** Stay tuned for the conclusion on management of serotonin syndrome **
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Category: Critical Care
Keywords: central line, cvc (PubMed Search)
Posted: 10/13/2015 by Feras Khan, MD
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Parienti et al. INtravascular complications of central venous catherization by insertion site. N ENGL J MED 373;13. Sept 24, 2015
Category: Visual Diagnosis
Posted: 10/12/2015 by Haney Mallemat, MD
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5 year-old boy who presents with sudden onset hoarse voice, and drooling without a fever.
Coin lodged in the esophagus
Coin ingestions
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Category: Toxicology
Keywords: hemodialysis, dabigatran, rebound (PubMed Search)
Posted: 10/7/2015 by Bryan Hayes, PharmD
(Updated: 10/8/2015)
Click here to contact Bryan Hayes, PharmD
In patients receiving renal replacement therapy as a treatment modality for dabigatran-related bleeding, watch for a rebound concentration increase after hemodialysis is stopped.
More than 50% of patients demonstrate a rebound effect with a median increase in dabigatran concentration of 33%.
It is unclear whether this rebound effect is clinically important, and whether it translates to prolonged clinically relevant bleeding. Extended hemodialysis sessions or consideration of CVVHD should offset this potential problem.
Bonus Pearl:
The North American Congress of Clinical Toxicology starts today and runs through October 12. Look for toxicology pearls and updates on Twitter under the official conference hashtag #NACCT15.
Chai- Adisaksopha C, et al. Hemodialysis for the treatment of dabigatran-associated bleeding: a case report and systematic review. J Thromb Haemost 2015;13(10):1790-8. [PMID 26270886]
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