This week's Pharmacy Phriday features a short excerpt from a longer podcast released as promo for the Colorado's CURE initiative, Clinicians United to Resolve the Epidemic, that combats the opioid crisis through education. Frequent contributor to the podcast, Rachael Duncan, PharmD, is joined by host, Elizabeth Esty, MD, to discuss the opioid prescribing guidelines for pharmacists released by the Colorado Hospital Association in collaboration with the Colorado Pharmacists Society. Colorado's CUR...
May 28, 2021•21 min
Contributor: Chris Holmes, MD Educational Pearls: Medicine is cyclical and practice is always evolving A description of recommended treatment for CHF from 1966 Give oxygen Give one dose morphine then switch to demerol Decrease venous return and start PPV Immediately apply tourniquet to 3 extremities rotating tourniquets every 20 minutes Phlebotomy of 350-500 cc blood into a donor bag and draw off plasma as RBCs settle down Give aminophylline (make sure it is warmed) Induce hypotension with nitro...
May 26, 2021•7 min
Contributor: Aaron Lessen, MD Educational Pearls: Facial nerve palsy (Bell’s palsy) can occur in pediatric patients with Lyme disease, viral infection, or even leukemia One trial sought out to find if steroids and acyclovir would benefit pediatric patients with facial nerve palsy However, during screening process, around 1% of enrollees had leukemia (5 of the 644 patients) This is important as steroids can partially treat the leukemia thereby prolonging diagnosis and put the patient at risk for ...
May 25, 2021•4 min
Contributor: Don Stader, MD Educational Pearls: Patients are more likely to survive an opioid overdose if they have naloxone 10% risk of death in the year following an opioid overdose of patients seen in the ED Those who receive naloxone: Have better survival rates Are more likely to enter recovery Are more likely to use the naloxone on another person who has overdosed Better to give the patient naloxone at discharge from the ED as rates of filling prescriptions are low Any patient who uses illi...
May 24, 2021•6 min
Contributor: Aaron Lessen , MD Educational Pearls: Patients on 10L or more of oxygen per minute in the ICU were randomized to oxygen goals of 90% or 96% to compare 90-day mortality rates Mortality rates were about 42% for both of oxygen target groups, indicating no significant difference References Schjørring OL, Klitgaard TL, Perner A, et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. N Engl J Med. 2021;384(14):1301-1311. doi:10.1056/NEJMoa2032510 Summarized by...
May 18, 2021•3 min
Contributor: Adam Barkin, MD Educational Pearls: Represents less than 1% of all fractures that occur, although it has a significant mortality rate of 2-5% Typically occurs in high-energy trauma and are commonly associated with high injury severity scores and other fractures Concomitant Injuries: 50% have rib fracture 25% have clavicle fracture 30% have a spine fracture 5% have a brachial plexus injury 40% have a pulmonary contusion 30% have a pneumothorax 34% have a head injury 11% have a vascul...
May 17, 2021•3 min
Contributor: Dave Rosenberg, MD Educational Pearls: In 1951, Operation Tat-Type began tattooing adults with their blood type in an effort to prepare for rapid transfusions in the time of the Cold War and the Korean War School children in northern Indiana and areas in Utah were tattooed with their blood type beginning in 1952 under the same operation Based on tattoos given to SS officers during WWII This wasn't to identify who needed what blood but rather to identify who could give what blood in ...
May 12, 2021•5 min
Contributor: Gretchen Hinson, MD Educational Pearls: Three episodes of ventricular tachycardia within 24 hours or two episodes back-to-back Treat with IV amiodarone and IV beta-blockers initially as well as IV lidocaine Correct underlying causes: IV magnesium for QT prolongation Replete potassium in hypokalemia Urgent revascularization in ischemia For refractory vtach, urgent radiofrequency ablation or stellate ganglion block can be done Last resort is placing on the patient on ECMO References M...
May 11, 2021•6 min
Contributor: Donald Stader, MD Educational Pearls: Opioids target kappa and NMDA receptors that can lead to central nervous system sensitization and therefore increased pain For patients with opioid-induced hyperalgesia (OIH), oral ketamine (25-50 mg) can be used to treat their pain as it targets the NMDA receptor Other treatments is IV magnesium, NSAIDs, tylenol, and clonidine Buprenorphine and methadone are options for chronic pain management in the setting of OIH References Lee M, Silverman S...
May 10, 2021•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Recent study looked at whether lactated ringers might be a better choice for fluid resuscitation in patients with DKA compared to normal saline Normal saline can cause a hyperchloremic metabolic acidosis Time to resolution of acidosis was 4 hours less with lactated ringers compared to normal saline Time on an insulin drip decreased by about 4 hours with lactated ringers compared to normal saline LR might be a better choice for fluid resuscitation...
May 04, 2021•3 min
Contributor: Jared Scott, MD Educational Pearls: About ½ of the patients in the ED present with some form of pain One study looked at patients presenting in pain and followed up two days after discharge to determine if their pain was addressed, asking if the patient received anything for pain and if the patient refused pain medication Non-analgesic pain management: About 30% discordance between patient reports and documentation Conventional analgesic pain management: About 15% discordance betwee...
May 03, 2021•5 min
Contributor: Peter Bakes, MD Educational Pearls: Incidence 2.5-10 per million people occurring primarily in those with environmental allergens Typically occurs with mRNA vaccines in lipid nanoparticles (Moderna/Pfizer) rather than the adenovirus vaccine (J&J) Recommendation is to forego 2nd dose of the mRNA vaccine and instead get the adenovirus vaccine after weighing the risks and benefits References Kounis NG, Koniari I, de Gregorio C, Velissaris D, Petalas K, Brinia A, Assimakopoulos SF, Gogo...
Apr 28, 2021•4 min
Contributor: Jared Scott, MD Educational Pearls: 1-3 cases of rabies per year in US with 55,000 people per year receiving rabies prophylaxis 90% of rabies cases come from wildlife, most commonly by racoons, bats, foxes, and skunks Because of rabies prophylaxis, domesticated pets almost never have rabies in the United States Rabies is typical transmitted via a bite, but direct contact with saliva or brain tissue on an open wound can transmit the virus Some people exposed to rabies from bats will ...
Apr 27, 2021•5 min
Contributor: Alicia Oberle, MD Educational Pearls: Down Syndrome with Trisomy 21 have three copies of chromosome 21 Current birth rates are around 1 in 700 births Average life span 25 years in 1980, today the average life span is 60 years of age Patients with Down syndrome require additional therapies in the first 3 years due to developmental delays They also have increased risk for childhood leukemias, seizures, hypothyroidism, celiac disease, and early-onset Alzheimers Half have a cardiac defe...
Apr 26, 2021•4 min
This week’s episode features a fascinating conversation with Dr. Nadia Tremonti, medical director for the pediatric palliative care program at Children’s Hospital of Michigan in Detroit. Dr. Tremonti was the featured physician in an independent short film Palliative and subsequent New York Times shorter excerpt Dying in your Mother’s Arms that explore her work with terminally ill pediatric patients. From conversations of religion’s role in processing disease to the physician’s role in alleviatin...
Apr 22, 2021•1 hr 3 min
Contributor: Aaron Lessen, MD Educational Pearls: Droperidol for sedation in agitated patients in the emergency department was studied compared to ziprasidone (Geodon) and lorazepam (Ativan) Double-blinded RCT showed droperidol was 65% effective to get patients to a good level of sedation in 15 minutes compared to ativan and geodon which were 25-35% effective Droperidol had less respiratory depression and prolongation of the QT compared to Ativan and Geodon References Martel ML, Driver BE, Miner...
Apr 21, 2021•4 min
Contributor: Ricky Dhaliwal, MD Educational Pearls: Primarily affects children Caused by staph aureus releasing exotoxins that result in erythema and sloughing of the skin Present with significant pain, dehydration and underlying staph infection Treatment typically oxacillin/nafcillin with admission for wound care with petroleum gel and xeroform Burn centers may be treatment centers of choice for this condition Most patients recover in 2-3 days with treatment References Patel GK, Finlay AY. Stap...
Apr 20, 2021•3 min
Contributor: Ricky Dhaliwal, MD Educational Pearls: Rhabdomyolysis occurs when high levels of myoglobin are released from dying muscle tissue into the blood Severe levels of myoglobin cause renal injury Causes include elevated temperature, excessive exercise, toxins, infection, muscle ischemia, crush injury, and prolonged immobilization Can also be caused by medications, like antipsychotics, statins, SSRIs, colchicine, lithium Workup typically includes creatinine kinase, potassium, creatinine le...
Apr 19, 2021•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Study in NEJM looked at occult hypoxemia, when oxygen saturation reads at >92% when the actual saturation is Rate of occult hypoxemia was 3 times higher in those who identified as black (12% vs 4%) Keep this disparity in mind when providing care to patients of all backgrounds and incorporate into clinical decision-making References Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 202...
Apr 14, 2021•3 min
Contributor: Peter Bakes, MD Educational Pearls: Febrile Seizure clinical criteria 6 months - 5 years of age Rapid rise in temp No preexisting seizure disorder No other explanation for the seizure Nonfocal seizure lasting less than 15 minutes If the seizure does not meet the above criteria, a full workup needs to be completed Regardless of cause, treat the seizure with IV/IO benzodiazepines or IN versed if unable to obtain access Risk of developing epilepsy after a simple febrile seizure roughly...
Apr 13, 2021•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Acid and alkali ingestions have differing prognosis and immediate concerns Immediate issues can include superficial irritation, severe burns, esophageal perforation, and even airway compromise from edem Long term morbidity can include strictures Supportive care is typically all that can be provided in the emergency department Diagnostics may include imaging and endoscopy For more severe ingestions without immediate issues,, patients may be monito...
Apr 12, 2021•3 min
Contributor: Peter Bakes, MD Educational Pearls: Lyme disease gives a single expanding target lesion with central clearing called erythema chronicum migrans Erythema multiforme is another targetoid rash that presents with multiple target lesions Characterized into erythema minor and major based on severity but typically resolves More severe hypersensitivity reactions include Stevens-Johnson Syndrome ( 30% skin involvement) SJS and TEN is associated with NSAIDS including aspirin, antiemetics like...
Apr 07, 2021•7 min
Contributor: Adam Barkin, MD Educational Pearls: Fever is an adaptive response to infection, but elderly and immunocompromised patients may not be able to mount a hyperthermic response in sepsis Patients with fever in sepsis end up receiving treatment earlier and have better outcomes Hypothermic patients with severe sepsis admitted to the ICU had a 32% mortality versus 21% mortality in those who had a fever on presentation 3-hour sepsis bundle compliance was less frequent in hypothermic patients...
Apr 06, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: Survey study compared depression symptom prevalence in the United States at the beginning of COVID compared to data acquired by a similar survey for 2017-2018 and found it was three-fold higher Mild symptoms: 25% during pandemic; 16% before Moderate: 15% during pandemic; 6% before Moderately Severe symptoms: 8% during pandemic; 2% before Severe symptoms: ~5% during pandemic; 1% before Those with lower income, less savings, and exposure to more st...
Apr 05, 2021•3 min
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Glucagon administered intravenously has a high rate of adverse events (nausea/vomiting) with very weak evidence NItroglycerin too has very limited evidence but a much better adverse event profile Mix 0.4 mg (1 sublingual tablet) nitro in 10 mL of water and administer orally Nothing beats upper endoscopy for effectiveness but in settings where GI is not immediately available, nitroglycerin may be worth an attempt given its better safety prof...
Mar 30, 2021•3 min
Contributor: Jared Scott, MD Educational Pearls: While it is rare to have a native hip dislocation, it is relatively common to dislocate a prosthetic hip The mechanism for dislocation is usually adduction, flexion, and internal rotation the hip which can occur when walking Arthroplasty in the setting of trauma or fracture, posterior approach during surgery, and using a small femoral head increase the likelihood of later dislocation If a patient with a total hip arthroplasty says they were walkin...
Mar 29, 2021•6 min
A heartfelt excerpt from our most recent UnfilterED episode with Dr. Don Stader.
Mar 26, 2021•20 min
Contributor: Katie Sprinkel, MD Educational Pearls: Hereditary angioedema (HA) is an autosomal dominant bradykinin-mediated disease affecting the airway, skin or gastrointestinal tract and typically presents with swelling in the absence of pruritus HA episodes last 3-5 days, typically occur first in childhood or adolescence, and decrease in frequency with aging Airway angioedema is the most dangerous but least common Skin angioedema is usually uncomfortable and should be monitored if involving t...
Mar 23, 2021•11 min
Contributor: Katie Sprinkel, MD Educational Pearls: Psychogenic Non-Epileptic Seizures (PNES) are due to a psychogenic rather than an epileptic cause Despite common assumption, PNES are not always volitional 20-40% of those with PNES can also have true epileptic seizures 20-40% True diagnosis requires a video EEG Characteristics of PNES include: Waxing and waning of the seizure intensity Eyes clenched shut Pelvic thrusting, rolling from side-to-side Ability to respond to verbal stimuli during th...
Mar 22, 2021•7 min
High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfold...
Mar 20, 2021•20 min
