Episode 913: Vasopressors after ROSC
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Recent study assessed outcomes after ROSC with epinephrine vs. norepinephrine Observational multicenter study from 2011-2018 285 patients received epineprhine and 481 received norepinephrine Epinephrine was associated with an increase in all-cause mortality (primary outcome) Odds ratio 2.6; 95%CI 1.4-4.7; P = 0.002 Higher cardiovascular mortality (secondary outcome) Higher proportion of unfavorable neurological outcome (secondary outcome) Norepinephrine is the vasopressor of choice in post-cardiac arrest care References ...
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Podcast 912: Narcan (Naloxone)
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Opioid Epidemic- quick facts Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45. In 2021, opioids were involved in nearly 75% of all drug overdose deaths The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths What is Narcan AKA Naloxone? Competitive opioid antagonist. It sits on the receptor but doesn’t activate it. When do we give Narcan?...
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Episode 911: Anticholinergic Toxicity
Emergency Medical Minute
Contributor: Taylor Lynch MD Educational Pearls: Anticholinergics are found in many medications, including over-the-counter remedies Medications include: Diphenhydramine Tricyclic antidepressants like amitriptyline Atropine Antipsychotics like olanzapine Antispasmodics - dicyclomine Jimsonweed Muscaria mushrooms Mechanism of action involves competitive antagonism of the muscarinic receptor Symptomatic presentation is easily remembered via the mnemonic: Dry as a bone - anhidrosis due to cholinergic antagonism at sweat glands Red as a beet - cutaneous vasodilation...
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Episode 910: Cellulitis Recovery Timeline
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How fast does cellulitis recover? A recent prospective cohort study took a look at this question. The study included 300 adults with cellulitis (excluding those with peri-orbital cellulitis or abscesses) in two emergency departments in Queensland, Australia. They collected data from initial and follow-up surveys at 3, 7, and 14 days, and compared clinician and patient assessments at day 14. Improvement was fastest between day 0 and day 3, with gradual progress thereafter. At day 14, many still had skin redness and swelling, though...
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Episode 909: Prehospital Blood Pressure Management in Suspected Stroke
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: A recent study assessed EMS treatment of high blood pressure in the field 2404 patients randomized to prehospital treatment (1205) vs. usual care (1199) Included patients with prehospital BP greater than 150 mm Hg The treatment arm’s BP goal was 130-140 mm Hg The primary efficacy outcome was functional status 90 days out Stroke was confirmed by imaging upon hospital arrival On arrival, the mean SBP of the treatment arm was 159 mm Hg compared with 170 mm Hg in the usual care group No significant difference in...
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Episode 908: Sympathomimetic Drugs
Emergency Medical Minute
Contributor: Taylor Lynch MD Educational Pearls: Overview: Sympathomimetic drugs mimic the fight or flight response, affecting monoamines such as dopamine, norepinephrine, and epinephrine Limited therapeutic use, often abused. Types: Amphetamines: Methamphetamine, Adderall, Ritalin, Vyvanse MDMA (Ecstasy) Cocaine (Both hydrochloride salt & free based crack cocaine) Theophylline (Asthma treatment) Ephedrine (For low blood pressure) BZP, Oxymetazoline (Afrin), Pseudoephedrine (Sudafed) MAO Inhibitors (treatment-resistant depression) Mechanisms: Act on adrenergic and dopaminergic...
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Episode 907: Wide-Complex Tachycardia
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Wide-complex tachycardia is defined as a heart rate > 100 BPM with a QRS width > 120 milliseconds Wide-complex tachycardia of supraventricular origin is known as SVT with aberrancy Aberrancy is due to bundle branch blocks Mostly benign Treated with adenosine or diltiazem Wide-complex tachycardia of ventricular origin is also known as VTach Originates from ventricular myocytes, which are poor inherent pacemakers Dangerous rhythm that can lead to death Treated with amiodarone or lidocaine 80% of wide-complex...
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Episode 906: Case Study of Hypernatremia
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: The case: A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered. His past medical history included previous strokes which had left him with deficits for which he required a feeding tube. Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145) Hypernatremia What causes it? Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as...
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Episode 905: Oseltamivir (Tamiflu) for Influenza
Emergency Medical Minute
Contributor: Aaron Lessem MD Educational Pearls: Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review) Benefit only occurs if taken within 48 hours of symptom onset Must be taken for 5 days A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization No reduction in hospitalizations with oseltamivir in patients over the age of 12 No difference in high-risk patients over the age of 65 or those...
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Episode 904: Cardiovascular Risks of Epinephrine
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective? A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question. Methods: Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine. The primary outcome was cardiotoxicity Results: Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included...
info_outlineContributor: Jared Scott MD
Educational Pearls:
Should we use opioids to treat low back and neck pain? The OPAL Trial, published in The Lancet, in June 2023, attempted to answer this very question.
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Objective: Investigate the efficacy and safety of a short course of opioid analgesic (oxycodone-naloxone) for acute low back pain and neck pain.
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Trial Design: Triple-blinded, placebo-controlled randomized trial, conducted in Emergency and Primary Care in Sydney, Australia, involving adults with 12 weeks or less of low back or neck pain.
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Participants: 347 recruited adults (174 in the opioid group, 173 in the placebo group) with at least moderate pain severity.
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Intervention: Participants were assigned to receive either an opioid or a placebo for up to 6 weeks.
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Primary Outcome: Pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale).
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Results: No significant difference in pain severity at 6 weeks between the opioid group (mean score 2.78) and placebo group (mean score 2.25).
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Adverse events were reported by 35% in the opioid group and 30% in the placebo group, with more opioid-related adverse events in the opioid group (e.g., constipation).
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Conclusion: Opioids should not be recommended for acute non-specific low back pain or neck pain, as there was no significant difference in pain severity compared with the placebo. The study calls for a change in the frequent use of opioids for these conditions.
Pharmacy Pearl: Why was naloxone mixed with oxycodone?
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Naloxone is an opioid receptor antagonist, meaning it can block the effects of opioids. When combined with oxycodone, naloxone's presence discourages certain forms of opioid misuse.
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Additionally, naloxone can bind to opioid receptors in the gut and improve symptoms of Opioid Induced Constipation (OIC).
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This is the same idea behind Suboxone (buprenorphine/naloxone).
References
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Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748.
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Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678.
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII