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8/16/2018 0 Comments

Pain Management in Our ED

Sergey Motov, MD
@painfreeED

General Principles:

Management of acute pain in the ED should be patient-centered and pan syndrome specific by using multimodal approach that include non-pharmacological modalities and pharmacological ones that include non-opioid and opioid analgesics.
Assessment of acute pain should be based on a need for analgesics to improve functionality, rather than patients-reported pain scores.
ED clinicians should engage patients in shared decision-making about overall treatment goals and expectations, the natural trajectory of the specific painful condition, and analgesic options including short-term and long-term benefits and risks of adverse effects.
When opioids are used for acute pain, ED clinicians should combine them with non-pharmacologic and non-opioid pharmacologic therapy: Yoga, exercise, cognitive behavioral therapy, complementary/alternative medical therapies (acupuncture); NSAID’s, Acetaminophen, Topical Analgesics, Nerve blocks, etc.
When considering opioids for acute pain, ED clinicians should involve patients in shared decision-making about analgesic options and opioid alternatives, risks and benefits of opioid therapies, and rational expectations about the pain trajectory and management approach.
When consider opioids for acute pain, EM providers should counsel patients regarding serious adverse effects such as sedation and respiratory depression; pruritus and constipation, and rapid development of tolerance and hyperalgesia
If acute pain lasting beyond the expected duration, complications of acute pain should be ruled out and transition to non-opioid therapy and non-pharmacological therapy should be attempted
When considering administration of opioids for acute pain, ED providers should make every effort to accesses respective state’s Prescription Drug Monitoring Program (PDMP). The data obtained from PDMP’s to be used to identify excessive dosages and dangerous combinations, identify and counsel patients with opioid use disorder, offer referral for addiction treatment.

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8/9/2018 0 Comments

What's in your Code Cart? Know your Meds

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8/5/2018 0 Comments

Hyperemesis Gravidarum

Hyperemesis Gravidarum:

Hyperemesis Gravidarum is severe nausea and vomiting during early pregnancy, typically starting prior to 9 weeks gestation.
- NOT associated with significant pain
- Do not turn off your brain, rule out serious causes before diagnosing the patient with hyperemesis gravidarum
Workup includes basic chemistry and urinalysis to evaluate electrolytes and signs of starvation ketosis
Confirm IUP
- Molar pregnancies or multiple gestation pregnancies can cause a higher amount of HCG and these patients are more likely to have hyperemesis.

First line treatment for this condition is Vitamin B6 and doxylamine. Some women will respond to P6 acupressure or ginger pills.
Treatment includes fluids with a source of glucose and antiemetics.
- Promethazine, metoclopromide, and ondansetron are all recommended options by the American College of Obstetrics and Gynecology (ACOG)[1].
- Ondansetron
  - There are insufficient data on fetal safety with ondansetron use and further studies are warranted
  - There have been studies that fetal exposure to ondansetron increases the risk of pediatric cardiac abnormalities and cleft palate; however, the data is inconsistent.
  - Individual studies of the association between ondansetron and congenital malformations are inconsistent, with some showing an increase in birth defects and others showing no difference [2,3,4]. A recent systematic review of ondansetron use in early pregnancy found eight studies that were adequate for inclusion [5]. Although there was a small increase in the risk of cardiac defects in two of the studies (odds ratio [OR], 2.0; 95% CI; 1.3-3.1 and OR, 1.62; 95% CI; 1.04-2.14), there was no increase in the overall rate of malformations in the ondansetron-exposed patients.
  - ACOG says, “Although some studies have shown an increased risk of birth defects with early ondansetron use, other studies have not. The absolute risk to any fetus is low.”
  - The American College of Obstetrics and Gynecology recommend Ondansetron as an option for patients not controlled on the first line medications Vitamin B6 and doxylamine.
  - Consult with your local Obstetricians

Erick, Miriam, et al. “ACOG Practice Bulletin 189.” Obstetrics & Gynecology, vol. 131, no. 5, 2018, p. 935., doi:10.1097/aog.0000000000002604.
Pasternak B, Svanstrom H, Hviid A. Ondansetron in pregnancy and risk of adverse fetal outcomes [published erratum appears in N Engl J Med 2013;368:2146]. N Engl J Med 2013;368:814–23.
Danielsson B, Wikner BN, Kallen B. Use of ondansetron during pregnancy and congenital malformations in the infant. Reprod Toxicol 2014;50:134–7.
Einarson A, Maltepe C, Navioz Y, Kennedy D, Tan MP, Koren G. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study. BJOG 2004;111:940–3.
Carstairs SD. Ondansetron use in pregnancy and birth defects: a systematic review. Obstet Gynecol 2016;127:878–83.

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8/2/2018 0 Comments

Pediatric Nasal Foreign Bodies

Background:

Most common site of foreign body insertion in children
Can be missed and remain for weeks or months
Population at risk:
- Children between 2–6 years-old most common
- Mental retardation
- Psychiatric illness
Complications:
- Sinusitis is the most common complication
- Septal perforation
- Bronchial aspiration
High risk of complications with button batteries:
- Mucosa ischemia
- Turbinate or septal damage -> Saddle-nose deformity

Etiology:

Organic vs. Inorganic
Button batteries: High risk of complications compared with other foreign bodies (tissue necrosis, septal perforation, saddle-nose deformity); require rapid removal!
- Septal perforation can occur in as little as 4 hours
Magnets (Used to mimic nasal piercing)
- May cause intestinal perforation if swallowed, especially newer high-powered neodymium magnets

Signs & Symptoms:

Most nasal foreign bodies are asymptomatic
Unilateral nasal obstruction with nasal pain
Purulent/foul-smelling nasal discharge
Persistent epistaxis

History:

Child witnessed putting object into nose or FB noticed by parent/caretaker
Many children are reluctant to admit to placing a foreign body for fear of adult disapproval
Child may present weeks after with nasal discharge and bleeding
*Often misdiagnosed at this stage as sinusitis

Diagnosis:

Laboratory studies usually unnecessary
Fiberoptic visualization if foreign body cannot be visualized on rhinoscopy
Sinus films if present for extended period or suspicion of battery or magnet
May need chest or abdomen films for aspiration/ingestion

Treatment:

Keep in sitting position to avoid posterior displacement and possible aspiration of foreign body
Avoid interventions that upset the child
Topical vasoconstrictors:
- Nebulized epinephrine
- Cocaine: 4%
- Oxymetazoline: 0.05%
- Phenylephrine: 0.125–0.5%

*NOT recommended for button batteries as may increase leakage of caustic materials

Hooked probe, alligator forceps
- Used for anterior foreign bodies that are easily grasped
Headlamp, nasal speculum will facilitate use!
Suction catheter can be used for round, smooth objects
Balloon catheters (or Katz extractor) can be used primarily when instrumentation fails
- Can use a 5F or 6F Foley or Fogarty balloon catheter lubricated with 2% lidocaine jelly
Positive pressure for children or the “parent’s kiss”
- Positive pressure applied to mouth only
- Parent may tell the child he or she will be given a “big kiss.”
- Deliver brisk puff as child begins to inhale
- Alternatively, deliver puff with a bag-valve mask over the mouth and O2 at 10–15 L/min.
Procedural sedation may be necessary
- Need availability of advanced airway as foreign body has potential for dislodgment posteriorly and aspiration!
Snare technique (for you MacGyver’s out there):
- 24-gauge wire made into a loop with a hemostat
- Slip through swollen tissue, behind object, pulling it free

Disposition:

Admission Criteria:
- Foreign body cannot be recovered in ED or posteriorly displaced
- Removal under general anesthesia is required
- Mucosal ischemia or turbinate/septal damage
Discharge Criteria
- Ensure that there is no airway compromise
- If a button battery was removed, monitor for delayed sequelae as outpatient
- May require follow-up with ENT if removal unsuccessful in ED or concern for nasal mucosa injury

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From the J. Lee Garvey Innovation Studio in the
Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC

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