Introducing CME for ALiEM via FOAMbase

foambase-aliem-logo-sml cmeEver wish you could get Continuing Medical Education (CME) credit for the Free Open Access Meducation (FOAM) you already consume? We are excited to announce that 10 ALiEM articles are now available for AMA PRA Category 1 CME. This is a pilot program in collaboration with FOAMbase and EB Medicine. There is great content on trauma, geriatrics, pediatrics, critical care, and more. We think CME for FOAM is going to be a great way to increase sustainability for FOAM authors while keeping FOAM 100% free and open access.

 

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2017-03-05T14:13:02-07:00

PEM Pearls: Perfecting your pediatric lumbar puncture using ultrasound

lp_collect-croppedA lumbar  puncture (LP) is a common procedure that every emergency physician must master. Pediatric LPs can be challenging for even the most experienced clinician due to small anatomy, difficulty with patient cooperation, and lack of frequency performed. A successful procedure is defined by obtaining cerebrospinal fluid and/or performing a non-traumatic lumbar puncture. There are multiple variables that lead to a successful pediatric lumbar puncture including provider experience, use of anesthesia, and patient positioning. Success rates for pediatric lumbar punctures are variable, with a large range from 34%-75%.1

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2017-10-26T14:33:32-07:00

Diagnosing the central slip injury

Extensor Tendon Laceration Finger 6 sm

Figure 1. Laceration overlying proximal interphalangeal (PIP) joint of right second digit. (Photograph by Daniel Ting and Jared Baylis)

A 34-year-old cabinet maker presents to your Emergency Department after accidentally getting his finger caught in a drawer. On examination, he has a superficial, clean laceration over the dorsal surface of the right second digit (Figure 1).

In a previous post, we discussed the approach to identifying, treating, and managing extensor tendon injuries of the hand. In it, we advocate for a high index of suspicion for extensor tendon injuries whenever a patient suffers a laceration to the dorsal aspect of the hand. However, lacerations over the PIP joint deserve special mention. In this article, we focus on the diagnosis of a specific type of extensor tendon laceration: the central slip injury.

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2017-03-11T00:19:16-07:00

Extensor tendon injuries of the hand: Emergency Department management

hand laceration -225x300You are working in the treatment area with a medical student and she is ready to review a “straightforward” case with you. She presents a young, healthy 27-year-old man with a laceration over the dorsal surface of the left hand after a kitchen mishap. It appears clean, and she doesn’t suspect a foreign body. The neurovascular status seems okay with the intact ability to extend the fingers. Her plan is to repair the wound and send the patient for follow up in 7 to 10 days with his family physician for suture removal. The wound appears superficial, but you are an astute clinician and wonder if the skin laceration might not be the only injury. Is there an associated extensor tendon injury?

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5 Tips for Managing Pain in Older Adults

painPain is the most common reason people seek care in Emergency Departments. In addition to diagnosing the cause of the pain, a major goal of emergency physicians (EPs) is to relieve pain. However, medications that treat pain can have their own set of problems and side effects. The risks of treatment are particularly pronounced in older adults, who are often more sensitive to the sedating effects of medications, and are more prone to side effects such as renal failure. EPs frequently have to find the balance between controlling pain and preventing side effects. Untreated pain has large personal, emotional, and financial costs, and more effective, multi-modal pain management can help reduce the burden that acute and chronic pain place on patients.1 There is evidence that older adults are less likely to receive pain medication in the ED.2,3 The first step to improving, is being aware of the potential tendency to under-treat pain in older adults. Here are 5 tips to help you effectively manage pain in older adults on your next shift.

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2016-12-16T15:29:06-07:00

Managing migraine headaches in complicated patients

migraineCase Vignette

A 42-year-old female presents at 10 pm with a throbbing right frontal headache associated with nausea, vomiting, photophobia, and phonophobia. The headache is severe, rated as “10” on a 0 to 10 triage pain scale. The headache began gradually while the patient was at work at 2 pm. Since 2 pm, she has taken 2 tablets of naproxen 500 mg and 2 tablets of sumatriptan 100 mg without relief.

The patient has a diagnosis of migraine without aura. She reports 12 attacks per month. The headache is similar to her previous migraine headaches. She is forced to present to an Emergency Department (ED) on average 2 times per month for management of migraine refractory to oral therapy. She reports a history of dystonic reactions and akathisia after receiving IV dopamine antagonists during a previous ED visit. The physical exam is non-contributory including a normal neurological exam, normal visual fields and fundoscopic exam, and no signs of a head or face infection. When you are done evaluating her, the patient reports that she usually gets relief with 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM, and asks that you administer her usual treatment. What do you do?

Background

Migraine is a neurological disorder characterized by recurrent painful headaches and abnormal processing of sensory input resulting in symptoms such as photophobia, phonophobia, and osmophobia.1 Central to disease pathogenesis is abnormal activation of nociceptive pathways.2 Disease severity ranges from mild to severe. Patients at one end of the spectrum have rare episodic headaches. On the other end are patients who have headaches on more days than not, patients who are functionally impaired by their headaches, and patients who frequently cannot participate fully in work or social activities. Chronic migraine, a sub-type of migraine defined by ≥15 days with headache for at least 3 consecutive months, is experienced by 1-3% of the general population.3

ED use for treatment of migraine is common. 1.2 million patients present to U.S. ED’s annually for management of this primary headache disorder.4 Parenteral opioids are used to treat the acute headache in slightly more than 50% of all ED visits.4 Multiple authorities have cautioned against the use of opioids for migraine.5,6 However, the frequent use of opioids has continued unabated, despite the publication in the EM, neurology, and headache literature of dozens of randomized controlled trials (RCTs) demonstrating safety and efficacy of parenteral alternatives, most notably dopamine antagonists and non-steroidal anti-inflammatory drugs.7

Opioids have been associated with a variety of poor outcomes in migraine patients including:

  1. Progression of the underlying migraine disorder from episodic to chronic migraine8
  2. Increased frequency of return visits to ED9
  3. Less responsiveness to subsequent treatment with triptans10
  4. Less frequent headache relief than patients who received dihydroergotamine or dopamine antagonists11

In contrast, a high quality, ED-based RCT did not demonstrate more harm from 1 or 2 doses of meperidine than from dihydroergotamine.12 Hydromorphone, the parenteral opioid currently used most commonly in U.S. EDs,4 has never been studied experimentally in migraine patients. However, given the wide range of parenteral alternatives, the possibility that opioids may worsen the underlying migraine disorder, and the fact that they are less efficacious than other treatments, opioids should not be offered as first- or second-line therapy for patients who present de novo to an ED with an acute migraine (assuming no contraindications to alternative medications).

Questions:

1) Other than opioids, what parenteral therapies can be offered to this patient?

The 3 classes of parenteral therapeutics with the most evidence supporting safety and efficacy for use as first-line therapy for migraine are the following13:

  1. Dopamine antagonists
  2. NSAIDs
  3. Subcutaneous sumatriptan

However, this patient has relative contraindications to each of these. Other parenteral medications used for migraine are listed in the following table.

Table: Alternative parenteral migraine therapies

Agent Dose Adverse events Evidence supporting efficacy Notes
Acetaminophen (APAP)14,15 1 gm IV Well tolerated In one trial, IV APAP did no better than placebo. In another, IV APAP was comparable to an IV NSAID.
Dihydroergotamine16 0.5 mg -1 mg IV infusion Nausea is common. Pre-treat with anti-emetics. In one trial, DHE was less effective than sumatriptan at 2 hours but more effective by 4 and 24 hours. Use cautiously in patients with cardiovascular risk factors.
Ketamine17 0.08 mg/kg SC Fatigue, delirium In one low quality cross-over RCT, ketamine outperformed placebo.
Magnesium18–21 1-2 gm IV Flushing In RCTs of varying quality, IV mg did not consistently outperform placebo Efficacy data is most compelling for migraine with aura.
Octreotide22 0.1 mg SC Diarrhea, injection site reactions In a high quality RCT, octreotide did not outperform placebo
Propofol23,24 10 mg IV every 10 minutes as needed up to 80 mg Or 30-40 mg IV with 10-20 mg bolus every 3-5 minutes up to 120 mg Sedation, hypoxia In a low quality RCT, propofol outperformed dexamethasone. In another low quality trial, propofol outperformed sumatriptan. It is not clear whether the migraine returns after propofol administration has been completed. Previous ALiEM post on migraines and propofol.
Valproic acid28,29 1000 mg IV Well tolerated In a high quality RCT, valproate was outperformed by metoclopramide and ketorolac. In a lower quality RCT, valproate was comparable to IV aspirin.
APAP= acetaminophen; DHE= dihydroergotamine; Mg= magnesium

In some patients, greater occipital nerve blocks with a long-acting local anesthetic such as bupivaciane may play a role.25 While the above alternative parenteral therapies may benefit this patient, available evidence regarding risks and benefits does not dictate that these other therapies must be offered prior to use of opioids.

2) Does the fact that this patient makes frequent use of the ED indicate an unmet medical need?

As with congestive heart failure and asthma, frequent use of an ED for migraine is associated with worse underlying disease.26 These frequent users are more likely to have chronic migraines (> 15 headache days per month) and psychiatric co-morbidities.26 Concomitant medication overuse headache, a disorder defined by an upward spiral of increasing headache frequency in the setting of increased usage of analgesic or migraine medication, is also common.27 Management of complicated patients with migraines is exceedingly difficult, particularly during a busy ED shift, and may lead to frustration for both the healthcare practitioner and the patient. Ideally, outpatient healthcare practitioners with appropriate expertise should direct management of complicated patients with migraines.

3) Should the patient be administered 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM as she wishes?

Management of chronic pain patients can be trying and demoralizing for emergency physicians because the underlying problem cannot be solved, and all avenues of treatment are flawed.  Allowing the patient to suffer without appropriate justification is cruel. Delaying opioid administration during good faith efforts to identify alternative effective therapeutic agents is reasonable. Withholding opioids on principle is problematic because for most patients in most circumstances, published data do not establish that the benefit of pain relief is outweighed by the potential for opioid induced harm. On the other hand, thoughtlessly acquiescing to repeated requests for opioids during multiple ED visits is a violation of good medical practice, because of the concern of exacerbating the underlying migraine disorder, which could result in more ED visits, increased number of headache days, and the potential to cause refractoriness to standard migraine medication. One might compare it to administering antibiotics for bronchitis.

Case Resolution

The best solution for the patient in the case vignette is to administer parenteral opioids only as rescue therapy for patients who adhere to an established outpatient plan of care. Acutely, the patient should not be allowed to suffer. However distasteful it may be, the harm arising from 3 isolated doses of parenteral opioids during one ED visit is unlikely to be either long-lasting or severe. But a prerequisite to treatment with opioids during a subsequent visit should be adherence to appropriate outpatient treatment: specifically, patients who require parenteral opioids for migraines should regularly attend outpatient appointments with an appropriate healthcare provider within the ED’s healthcare system.

Department-wide opioid policies are essential, as physician to physician variability in care may undermine a strict approach to opioids. Ideally, a committee with relevant expertise can monitor frequently presenting pain patients and develop patient-specific interventions that will be enforced by all practitioners during subsequent visits. If need be, the terms of treatment can be reinforced with a written document (example in the Appendix). This written document is not meant to be legally binding, but should be used to establish expectations. The last thing a busy emergency physician needs is a battle over opioids with a frequently presenting migraine patient. But before discharge, there should be a conversation about expectations during future ED visits. This will contribute to increased satisfaction for both the provider and the patient.

Top image: (c) Can Stock Photo

Migraine and opioids

A written understanding between the staff of the emergency department and ______.

As providers of emergency healthcare 24 hours per day, seven days per week, we take enormous pride in our ability to provide top-notch care. We save lives, treat pain and illness, and work hard to ensure the best possible health for all of our patients. We are asking you to sign this agreement because we believe that together, you and we can do a better job of managing your headaches.

You have a migraine. A migraine is a chronic headache disorder. For reasons that are still unclear to scientists, the brains of patients with migraines experience pain differently than people without migraine. The result of this is horrible headaches and other symptoms like nausea, vomiting, sensitivity to light and sound, and dizziness. There are effective treatments for migraines. Some patients with migraines take medications every day to prevent headaches from even beginning. Some patients with migraine receive injections to decrease the number of headaches they experience. Some patients learn techniques to take control of the pain once it begins.

We have noticed that because of your headaches, you have to come to the emergency department (ED) to get treatment frequently. When you come to the ED, the only medication that helps your headache is an opioid medication. Examples of opioid medications include: hydromorphone (Dilaudid), meperidine (Demerol), morphine, butorphanol, oxycodone (Percocet, Oxycontin). We want to work with you to decrease the number of times that you have to come to the ED to get treatment for migraine. Based on published scientific studies, we think that treating migraines with opioid medications may be worsening your migraines. We understand that opioid medications make you feel better quickly, but ultimately, they may be doing more harm than good. Therefore, we want to limit the number of doses of opioids that you receive in the ED. With that goal in mind, we are going to require the following prior to giving you opioid injections in the ED.

  • You need to establish a relationship with a doctor who can help you manage your migraines. The names and contact numbers of some doctors we recommend are listed below. You may use your own doctor, but the doctor must be experienced in the management of headache or pain, must be local, and must be willing to be available by telephone whenever you are in the ED
  • Every ED visit must be followed up with a visit to that doctor
  • You need to make a good faith effort to reduce the number of times you visit the ED for your treatment of migraines.

References

1.
Headache C. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. [PubMed]
2.
Goadsby P. Pathophysiology of migraine. Ann Indian Acad Neurol. 2012;15(Suppl 1):S15-22. [PubMed]
3.
Lipton R. Chronic migraine, classification, differential diagnosis, and epidemiology. Headache. 2011;51 Suppl 2:77-83. [PubMed]
4.
Friedman B, West J, Vinson D, Minen M, Restivo A, Gallagher E. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35(4):301-309. [PubMed]
5.
Langer-Gould A, Anderson W, Armstrong M, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011. [PubMed]
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Loder E, Weizenbaum E, Frishberg B, Silberstein S, American H. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659. [PubMed]
7.
Sumamo S, Dryden D, Pasichnyk D, et al. Acute Migraine Treatment in Emergency Settings. November 2012. http://www.ncbi.nlm.nih.gov/books/NBK115368/. [PubMed]
8.
Bigal M, Serrano D, Buse D, Scher A, Stewart W, Lipton R. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48(8):1157-1168. [PubMed]
9.
Colman I, Rothney A, Wright S, Zilkalns B, Rowe B. Use of narcotic analgesics in the emergency department treatment of migraine headache. Neurology. 2004;62(10):1695-1700. [PubMed]
10.
Burstein R, Collins B, Jakubowski M. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia. Ann Neurol. 2004;55(1):19-26. [PubMed]
11.
Friedman B, Kapoor A, Friedman M, Hochberg M, Rowe B. The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med. 2008;52(6):705-713. [PubMed]
12.
Carleton S, Shesser R, Pietrzak M, et al. Double-blind, multicenter trial to compare the efficacy of intramuscular dihydroergotamine plus hydroxyzine versus intramuscular meperidine plus hydroxyzine for the emergency department treatment of acute migraine headache. Ann Emerg Med. 1998;32(2):129-138. [PubMed]
13.
Orr S, Aubé M, Becker W, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2015;35(3):271-284. [PubMed]
14.
Turkcuer I, Serinken M, Eken C, et al. Intravenous paracetamol versus dexketoprofen in acute migraine attack in the emergency department: a randomised clinical trial. Emerg Med J. 2014;31(3):182-185. [PubMed]
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Leinisch E, Evers S, Kaempfe N, et al. Evaluation of the efficacy of intravenous acetaminophen in the treatment of acute migraine attacks: a double-blind, placebo-controlled parallel group multicenter study. Pain. 2005;117(3):396-400. [PubMed]
16.
Winner P, Ricalde O, Le F, Saper J, Margul B. A double-blind study of subcutaneous dihydroergotamine vs subcutaneous sumatriptan in the treatment of acute migraine. Arch Neurol. 1996;53(2):180-184. [PubMed]
17.
Nicolodi M, Sicuteri F. Exploration of NMDA receptors in migraine: therapeutic and theoretic implications. Int J Clin Pharmacol Res. 1995;15(5-6):181-189. [PubMed]
18.
Corbo J, Esses D, Bijur P, Iannaccone R, Gallagher E. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med. 2001;38(6):621-627. [PubMed]
19.
Shahrami A, Assarzadegan F, Hatamabadi H, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med. 2015;48(1):69-76. [PubMed]
20.
Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia. 2005;25(3):199-204. [PubMed]
21.
Bigal M, Bordini C, Tepper S, Speciali J. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia. 2002;22(5):345-353. [PubMed]
22.
Levy M, Matharu M, Bhola R, Meeran K, Goadsby P. Octreotide is not effective in the acute treatment of migraine. Cephalalgia. 2005;25(1):48-55. [PubMed]
23.
Soleimanpour H, Taheraghdam A, Ghafouri R, Taghizadieh A, Marjany K, Soleimanpour M. Improvement of refractory migraine headache by propofol: case series. Int J Emerg Med. 2012;5(1):19. [PubMed]
24.
Moshtaghion H, Heiranizadeh N, Rahimdel A, Esmaeili A, Hashemian H, Hekmatimoghaddam S. The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A Double-Blinded Clinical Trial. Pain Pract. 2015;15(8):701-705. [PubMed]
25.
Voigt C, Murphy M. Occipital nerve blocks in the treatment of headaches: safety and efficacy. J Emerg Med. 2015;48(1):115-129. [PubMed]
26.
Friedman B, Serrano D, Reed M, Diamond M, Lipton R. Use of the emergency department for severe headache. A population-based study. Headache. 2009;49(1):21-30. [PubMed]
27.
Kristoffersen E, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment. Ther Adv Drug Saf. 2014;5(2):87-99. [PubMed]
28.
Leniger T, Pageler L, Stude P, Diener H, Limmroth V. Comparison of intravenous valproate with intravenous lysine-acetylsalicylic acid in acute migraine attacks. Headache. 2005;45(1):42-46. [PubMed]
29.
Friedman B, Garber L, Yoon A, et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014;82(11):976-983. [PubMed]
2019-04-28T21:14:07-07:00

Trick of the Trade: Pre-Charge the Defibrillator

Pre-Charge the Defibrillator CPRIn cardiac arrest care it is well accepted that time to defibrillation is closely correlated with survival and outcome.1 There has also been a lot of focus over the years on limiting interruptions in chest compressions during CPR. In fact, this concept has become a major focus of the current AHA Guidelines. Why? Because we know interruptions are bad.2,3 One particular aspect of CPR that has gotten a lot of attention in this regard is the peri-shock period. It has been well established that longer pre- and peri-shock pauses are independently associated with decreased chance of survival.4,5 Can we do better to shock sooner and minimize these pauses?

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