estimating children weights - consider the paper by Timothy P. Young et al 'Finger Counting: an alternative method for estimating paediatric weights" in American Journal of Emergency Medicine 32 (2014) 243-247 Its a easier to remember than a formula, and as the conclusion says "...is an acceptable alternative to the Broselow method in children aged 1 to 9. It outperforms the traditional APLS method but underestimates weights compared with parental estimate and the Luscombe formula"
Hello Dr. Orman, this is Dr. Diaz-Miranda from Newport Medical Center ER in TN. I have gone through half of this months emrap and when I listened to the critical care mail bag I always get excited because I learn so much from Dr. Weingart. However, I was very surprised to hear the conversation about the swelling tongue and sitting watching to see how things will go and not to intubate. With all due respect to him, when I see those type of patients in my ED, where it is only the nurses and I, with no other help, I go and put the tube down the airway and then after the intubation I feel more comfortable sitting watching to see how things will go. As usual, thank you for a job well done. Tino
Dr. Constantino: I generally agree. If there is more than minimal tongue swelling, and certainly if there is moderate tongue swelling, I intubate early rather than late. I've seen too many people go from comfortable to extremis within 15 min. Just last month, I had a gentleman with moderate tongue swelling who seemed perfectly comfortable. I spent about 3 minutes evaluating him and made the decision to intubate him. 17 minutes later, when the drugs were pushed, he had begun to experience trouble breathing and his tongue had become 2-3 times the size it was when he presented.
Regarding something for pain: I felt the vast majority of this presentation was spot on, but I do have a few comments. Although Dr. Strayer asserts that hydrocodone and oxycodone are more euphoric there is little to no literature that I or my clinical pharmacist can find to support this claim. Morphine causes more nausea and more constipation than either hydrocodone or oxycodone. The fact that hydrocodone and oxycodone are more abused is likely related to the fact that they are prescribed more often. I think changing to morphine does not actually dimish risks to my patient and will likely simply cause raised eyebrows in my collegues when these patients follow up. If there is good literature I missed let me know.
John - you are right to question the advocacy of morphine IR. I've looked at this question pretty carefully, and, as you say, there isn't great science here. but there is some science. Here are a group of papers that to one degree or another implicate the codones.
Yes, a lot of what's driving the disproportionate abuse rates are what we prescribe, and american emergency providers prescribe codones almost exclusively. But if you look through these papers, and look at the internet message boards (in that folder are some quotes I found while browsing them a couple years ago, trying to answer this question), it becomes pretty clear that oxy and hydro are more abuse-prone than alternatives.
Sergey Motov is studying this now, we may have some better science soon. But let's also remember that we adopted percocet and vicodin wholesale on no evidence–vicodin is the most prescribed drug in the country because we have been effectively marketed to. So I'm not sure we need bulletproof data to change practice.
Lastly, the choice of opioid is much less important than the other elements of responsible opioid use: nearly every patient currently discharged from EDs with opioids would do quite well with alternatives. The most important thing we can do to reduce the burden of opioid harms in our community is to prescribe to fewer opioid naive patients. And if you do prescribe, prescribe a small number to last only a couple of days.
Reuben; what are your thoughts on this recent MMWR published on CDC website (https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm?s_cid=mm6610a1_e) ; it looked at characteristics of long-term abuse risk and found higher abuse in patients given "short-acting opioid other than hydrocodone or oxycodone" then in hydrocodone and oxycodone - https://stacks.cdc.gov/view/cdc/44181. This would argue against choosing Morphine IR for those with pain.
Again this does not change the other elements that you discuss - that are more important; but I was considering changing my practice to using Morphine IR prescriptions; now I am back on the fence and may lean towards hydrocodone for short prescriptions.
I would love to see a breakdown of the category "short-acting opioid other than hydro/oxycodone," note that this category would include hydromorphone among others, hard to know what's driving the higher number they report.
Likability data is weak but it all points in one direction: oxycodone is the most euphoric. Just last night I saw a patient with misuse flags demanding an opioid prescription. I offered her five MSIR tabs. She said, are those the pink pills? I nodded. She turned to her companion, he shook his head, and they got up and walked out.
This is an important topic and a great discussion. I'm also considering changing my practice based on the presentation and discussion here. I recall in the podcast that I could a stack of the SAMHSA help line cards by commenting here. How might I go about this?
What is the GI Bleeding risk of using Morin 400 mg four times a day for pain ?
How is this 400 mg of Motrin 4 times a day for chronic pain safer than narcotics?
Do we start all patients we put on high dose NSAIDS on PPI's?
Do we screne all the patients we put on high dose NSAID's for H,Pylori and then treat all those who are positive with quadrupal antibiotic threrapy to try to eradicate the H.Pylori in an attempt to prevent bleeding GI ulcers?
Jonathan - excellent questions. I'm looking for hard info on GI bleeding risk and I'll get back to you. We know there's an increase, typically with longer term, high dose use but from my recollection, in low risk patients, the increase is minimal. Stand by for more.
It's not unreasonable if you're giving a longer course of NSAID to give a PPI. that's my standard practice in pericarditis treatment and I think many people do the same. Typically, though, I'm only prescribing 7-10 days worth of NSAID so I'm not as concerned.
As far as H. Pylori, the answer would be no. If the patient has symptoms concerning for H. Pylori, I refer for testing though there was an ED study of testing in Annals about 18 months ago.
Have some info for you on the topic: This is an excellent link detailing all of the issues (and free): http://pharmacistsletter.therapeuticresearch.com/pl/ArticlePDF.aspx?cs=&s=PL&DocumentFileID=0&DetailID=330101&SegmentID=0 Bottom line is that GI bleed risk with ibuprofen is low but it's reasonable to consider patient risks before prescribing
As an alternative to "calling" an admit: there are now HIPPA compliant texting apps (like QLIQ) that allow you to do an organized, coherent written summary that allows you to edit (oops, forgot to mention that the K+ was 1.1), doesn't require you to interrupt the admitting doc, doesn't require multiple phone calls (I'll have Dr J take that admit, I've forwarded your note to her), with a little copy and paste becomes your admission executive summary, and avoids interruptions. It can be brief (I've got a floor admit for you, leg cellulitis in a diabetic - call me for details). Or, can be a brief summary followed by all the details - lab, imaging, comorbidities, and treatments initiated. Saves a lot of time and hair pulling.
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Kevin G. - March 3, 2017 1:57 AM
estimating children weights - consider the paper by Timothy P. Young et al 'Finger Counting: an alternative method for estimating paediatric weights" in American Journal of Emergency Medicine 32 (2014) 243-247
Its a easier to remember than a formula, and as the conclusion says "...is an acceptable alternative to the Broselow method in children aged 1 to 9. It outperforms the traditional APLS method but underestimates weights compared with parental estimate and the Luscombe formula"
Constantino D. - March 6, 2017 2:17 PM
Hello Dr. Orman, this is Dr. Diaz-Miranda from Newport Medical Center ER in TN. I have gone through half of this months emrap and when I listened to the critical care mail bag I always get excited because I learn so much from Dr. Weingart. However, I was very surprised to hear the conversation about the swelling tongue and sitting watching to see how things will go and not to intubate. With all due respect to him, when I see those type of patients in my ED, where it is only the nurses and I, with no other help, I go and put the tube down the airway and then after the intubation I feel more comfortable sitting watching to see how things will go. As usual, thank you for a job well done. Tino
Kevin M. - April 13, 2017 7:08 AM
Dr. Constantino: I generally agree. If there is more than minimal tongue swelling, and certainly if there is moderate tongue swelling, I intubate early rather than late. I've seen too many people go from comfortable to extremis within 15 min. Just last month, I had a gentleman with moderate tongue swelling who seemed perfectly comfortable. I spent about 3 minutes evaluating him and made the decision to intubate him. 17 minutes later, when the drugs were pushed, he had begun to experience trouble breathing and his tongue had become 2-3 times the size it was when he presented.
John M. - March 7, 2017 1:11 PM
Regarding something for pain: I felt the vast majority of this presentation was spot on, but I do have a few comments. Although Dr. Strayer asserts that hydrocodone and oxycodone are more euphoric there is little to no literature that I or my clinical pharmacist can find to support this claim. Morphine causes more nausea and more constipation than either hydrocodone or oxycodone. The fact that hydrocodone and oxycodone are more abused is likely related to the fact that they are prescribed more often. I think changing to morphine does not actually dimish risks to my patient and will likely simply cause raised eyebrows in my collegues when these patients follow up. If there is good literature I missed let me know.
Mark D. - April 7, 2017 7:08 AM
{Wightman,Likeability and abuse liability of commonly prescribed opioids Journal of Medical Toxicology volume 8 issue 4 , pg 335-340
Reuben Strayer (@emupdates) - March 7, 2017 9:26 PM
John - you are right to question the advocacy of morphine IR. I've looked at this question pretty carefully, and, as you say, there isn't great science here. but there is some science. Here are a group of papers that to one degree or another implicate the codones.
https://www.dropbox.com/sh/nyrvusd43tdgua6/AABV2-5USj4848_7-yJ1cv1Ya?dl=0
Yes, a lot of what's driving the disproportionate abuse rates are what we prescribe, and american emergency providers prescribe codones almost exclusively. But if you look through these papers, and look at the internet message boards (in that folder are some quotes I found while browsing them a couple years ago, trying to answer this question), it becomes pretty clear that oxy and hydro are more abuse-prone than alternatives.
Sergey Motov is studying this now, we may have some better science soon. But let's also remember that we adopted percocet and vicodin wholesale on no evidence–vicodin is the most prescribed drug in the country because we have been effectively marketed to. So I'm not sure we need bulletproof data to change practice.
Lastly, the choice of opioid is much less important than the other elements of responsible opioid use: nearly every patient currently discharged from EDs with opioids would do quite well with alternatives. The most important thing we can do to reduce the burden of opioid harms in our community is to prescribe to fewer opioid naive patients. And if you do prescribe, prescribe a small number to last only a couple of days.
thanks for your comments.
reuben
GHS, MD - April 2, 2017 7:46 PM
Reuben; what are your thoughts on this recent MMWR published on CDC website (https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm?s_cid=mm6610a1_e) ; it looked at characteristics of long-term abuse risk and found higher abuse in patients given "short-acting opioid other than hydrocodone or oxycodone" then in hydrocodone and oxycodone - https://stacks.cdc.gov/view/cdc/44181. This would argue against choosing Morphine IR for those with pain.
Again this does not change the other elements that you discuss - that are more important; but I was considering changing my practice to using Morphine IR prescriptions; now I am back on the fence and may lean towards hydrocodone for short prescriptions.
Reuben Strayer (@emupdates) - April 3, 2017 6:12 AM
I would love to see a breakdown of the category "short-acting opioid other than hydro/oxycodone," note that this category would include hydromorphone among others, hard to know what's driving the higher number they report.
Likability data is weak but it all points in one direction: oxycodone is the most euphoric. Just last night I saw a patient with misuse flags demanding an opioid prescription. I offered her five MSIR tabs. She said, are those the pink pills? I nodded. She turned to her companion, he shook his head, and they got up and walked out.
Ronald R. - May 8, 2017 4:47 AM
This is an important topic and a great discussion. I'm also considering changing my practice based on the presentation and discussion here. I recall in the podcast that I could a stack of the SAMHSA help line cards by commenting here. How might I go about this?
Reuben Strayer (@emupdates) - May 8, 2017 5:16 PM
Ronald - send your mailing address to me and I'll ship some cards to you.
emupdates@gmail.com
Jonathan W. - March 13, 2017 8:39 PM
What is the GI Bleeding risk of using Morin 400 mg four times a day for pain ?
How is this 400 mg of Motrin 4 times a day for chronic pain safer than narcotics?
Do we start all patients we put on high dose NSAIDS on PPI's?
Do we screne all the patients we put on high dose NSAID's for H,Pylori and then treat all those who are positive with quadrupal antibiotic threrapy to try to eradicate the H.Pylori in an attempt to prevent bleeding GI ulcers?
Jonathan Wasserberger
Anand S. - March 14, 2017 9:55 AM
Jonathan - excellent questions. I'm looking for hard info on GI bleeding risk and I'll get back to you. We know there's an increase, typically with longer term, high dose use but from my recollection, in low risk patients, the increase is minimal. Stand by for more.
It's not unreasonable if you're giving a longer course of NSAID to give a PPI. that's my standard practice in pericarditis treatment and I think many people do the same. Typically, though, I'm only prescribing 7-10 days worth of NSAID so I'm not as concerned.
As far as H. Pylori, the answer would be no. If the patient has symptoms concerning for H. Pylori, I refer for testing though there was an ED study of testing in Annals about 18 months ago.
Anand S. - March 15, 2017 6:03 AM
Jonathan,
Have some info for you on the topic:
This is an excellent link detailing all of the issues (and free): http://pharmacistsletter.therapeuticresearch.com/pl/ArticlePDF.aspx?cs=&s=PL&DocumentFileID=0&DetailID=330101&SegmentID=0
Bottom line is that GI bleed risk with ibuprofen is low but it's reasonable to consider patient risks before prescribing
Rabbott - March 15, 2017 9:35 AM
As an alternative to "calling" an admit: there are now HIPPA compliant texting apps (like QLIQ) that allow you to do an organized, coherent written summary that allows you to edit (oops, forgot to mention that the K+ was 1.1), doesn't require you to interrupt the admitting doc, doesn't require multiple phone calls (I'll have Dr J take that admit, I've forwarded your note to her), with a little copy and paste becomes your admission executive summary, and avoids interruptions. It can be brief (I've got a floor admit for you, leg cellulitis in a diabetic - call me for details). Or, can be a brief summary followed by all the details - lab, imaging, comorbidities, and treatments initiated. Saves a lot of time and hair pulling.