Management of Opioid Use Disorder in the Emergency Department

Introduction

Over the past year, a group of physicians and pharmacists with expertise in emergency medicine, toxicology, and addiction medicine developed a white paper for the American Academy of Emergency Medicine (AAEM) on Management of Opioid Use Disorder in the Emergency Department. It is our attempt to share current best practices and provide comprehensive evidence-based recommendations for providers in acute care settings managing patients being harmed-or at risk to be harmed-by opioids.

The guideline is set up as 48 discrete, commonly-encountered questions with extensively-referenced, high-yield answers answer based on available evidence and expert consensus within our group.

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2018 AHA Focused Update

Background

The year 2005 was full of milestones, YouTube was founded in February and it was also the last time lidocaine was included in the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Adult Cardiac Arrest Algorithm.1 Since 2010, we have been directed by the guidelines to utilize amiodarone as the sole first-line antidysrhythmic.2 At the same time, there has been an increased focus on early defibrillation and proper CPR technique as opposed to medication administration. In 2015, the International Liaison Committee on Resuscitation (ILCOR) moved away from publishing guideline updates every 5 years to a continuous process wherein they provide updates as the literature dictates.3

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Low-dose vs. High-dose Magnesium in Rapid Afib

Magnesium sulfate has been used as an adjunct medication for the treatment of atrial fibrillation (AF) due to its ability to lessen sinus node depolarization via calcium antagonism. Prior studies investigating magnesium in rapid AF administered varying dosages, often targeted post-surgical patients, and had small sample sizes. Dr. Bryan Hayes summarized previous studies on Academic Life in Emergency Medicine in 2016, focusing on IV magnesium for rate-control in ED-related settings and concluded it to be safe and moderately effective for reducing heart rate in rapid AF.

A new 2018 study by Bouida and colleagues aimed to determine the benefit of two different magnesium doses vs. placebo to control ventricular rate in ED patients with AF, when used with an AV nodal blocking agent.

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Ketamine for Acute Geriatric Pain in the ED

Subdissociative-dose ketamine (SDK) provides effective analgesia with lower rates of unwanted side effects when administered as a slow IV infusion. However, safety and efficacy studies have excluded geriatric patients until now, when Dr. Sergey Motov and colleagues strike again. SDK offers a much-needed pain management strategy for moderate to severe pain in this population who are often not ideal candidates for opioid analgesia.

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Nitrofurantoin vs. Fosfomycin for Uncomplicated UTI

Background

Nitrofurantoin and fosfomycin are both recommended by the IDSA guidelines as first-line options in the treatment of uncomplicated cystitis due to their low resistance rates and minimal collateral damage. However, deciding which to choose is often based on convenience or habit, rather than supported by literature. This study was performed to compare sustained clinical resolution and microbiologic response between these two agents in middle-aged women with uncomplicated lower urinary tract infections.

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Ondansetron and QTc Prolongation: Clinical Significance in the ED

Background

Just like many other medications, ondansetron can prolong the QTc interval on an electrocardiogram. In fact, the FDA released a Drug Safety Communication in 2012 recommending against IV doses > 16 mg to help limit the risk. A prospective, observational study in 40 cardiac patients (heart failure or ACS) found that ondansetron 4 mg IV prolonged the QTc interval by 19 msec for up to 2 hours after the dose (Hafermann, Drug Healthc Patient Safety 2011). A retrospective cohort study of 210 ondansetron doses in pediatric ICU patients found that the QTC  interval increased to 460-500 msec in 29% and to more than 500 msec in 11% (Trivedi, Pediatr Crit Care Med 2016). Underlying electrolyte abnormalities and organ dysfunction seemed to add the most risk.

But, what about in ED patients? What is the extent of QTC prolongation and is it clinically significant? Two groups have now published on this patient population. Here’s what they found.

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Topical TXA for Epistaxis in Patients on Antiplatelet Agents

Epistaxis is a common emergency department (ED) presentation, particularly in patients on antiplatelet and anticoagulation agents. Traditional remedies for bleeding include local vasoconstrictors, silver nitrate, and anterior nasal packing (ANP), each with variable efficacy. In recent years tranexamic acid (TXA) applied topically has gained popularity due to its efficacy, minimal systemic absorption lending to a low side-effect profile, and ease of use for the patient and provider (Zahed, Am J Emerg Med 2013; Ker, Cochrane Database Syst Rev 2013). In this recently published study, Zahed et al narrowed their focus to explore clinical efficacy of topical TXA in patients on antiplatelet agents (aspirin, clopidogrel, or both).

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