Emergency Medical Minute

RACTICE RECOMMENDATIONS 1. Opioids are inherently dangerous, highly addictive drugs with significant abuse potential, numerous side effects, lethality in overdose, rapid development of tolerance, and debilitating withdrawal symptoms. They should be avoided whenever possible and, in most cases, initiated only after other modalities of pain control have been trialed. 2. Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for abuse, addiction, or adverse reactions. 3. Emergency physicians should frequently consult Colorado's prescription drug monitoring program (PDMP) to assess a patient's history of prescription drug abuse, misuse, or diversion. 4. Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid prescribing patterns with their clinicians to decrease protocol variabilities. 5. Strongly consider removing prepopulated doses of opioids from order sets in computerized provider order entry (CPOE) systems. 6. Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed. 7. Potential drug interactions must be evaluated, and opioids should be avoided in patients already taking benzodiazepines, barbiturates, or other narcotics. 8. Patients with chronic pain should receive opioid medications from one practice, preferably their primary care provider or pain specialist. Opioids should be avoided in the emergency department treatment of most chronic conditions. Emergency physicians should coordinate care with a patient's primary care or pain specialist whenever possible, and previous patient-physician contracts regarding opioid use should be honored. 9. Clinicians should abstain from adjusting opioid dosing regimens for chronic conditions and avoid routinely prescribing opioids for acute exacerbations of chronic noncancer pain. 10. "Long-acting" or "extended-release" opioid products should be avoided for the relief of acute pain. 11. Patients receiving controlled medication prescriptions should be able to verify their identity. 12. Patients who receive opioids should be educated about their side effects and potential for addiction, particularly when being discharged with an opioid prescription. 13. When considering opioids, clinicians should prescribe the lowest possible effective dose in the shortest appropriate duration (eg, <3 days). 14. Emergency departments should refuse to refill lost or stolen opioid prescriptions. POLICY RECOMMENDATIONS 1. As has been done in other states, the Colorado PDMP should develop an automated query system that can be more readily integrated into electronic health records and accessed by emergency clinicians. 2. Pain control should be removed from patient satisfaction surveys, as they may unfairly penalize physicians for exercising proper medical judgement. 3. Opioid prepacks should be avoided or eliminated in the emergency department if 24-hour pharmacy support is available. 4. Pain should not be considered the "fifth vital sign."

The Emergency Medical Minute proudly presents an educational podcast series sponsored by the Colorado Hospital Association addressing our the United States' opioid epidemic.

Author: Donald Stader, M.D. Educational Pearls: The most common ankle injury mechanism is an inversion. Most common broken bone in the ankle is the fibula. During exam, it is important to palpate over the fibular head, medial and lateral malleoli, over the 5th metatarsal and over the cuboid bone. If no tenderness in these areas and the patient is walking - they have a sprain and can be sent home without imaging. In calcaneal fractures, make sure to image the lumbar spine since up to 30% of calcaneal fractures are associated with lumbar spine injury. References: http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-info/ankle-physical-examination/

Author: Aaron Lessen, M.D. Educational Pearls: We can differentiate verto into benign problems such as vestibular problem (peripheral problem), or something more worrisome that originates in the brain (central problem). Dizziness + other symptoms makes us think about origination in the CNS. Symptoms include Dizziness, Diplopia, Dysarthria, Dysphagia, Dysmetria. References: http://www.medicalnewstoday.com/knowledge/160900/vertigo-causes-symptoms-treatments http://www.mayoclinic.org/diseases-conditions/dizziness/basics/causes/con-20023004

Author: Michael Hunt, M.D. Educational Pearls: Oats have been shown to lower LDL. Oat bran is the most effective way to consume oats to lower LDL. A Swedish study of 69,000 people who ate at least 3 servings of potatoes a week showed no increased risk of a MI or stroke associated with potato consumption. References: Larsson SC, Wolk A. Potato consumption and risk of cardiovascular disease: 2 prospective cohort studies. Am J Clin Nutr. 2016

Author: Jared Scott, M.D. Educational Pearls: A pessary is a device inserted into the vagina for medical purposes. Examples include birth control and mechanical support of the pelvic structures. In older women, collapse of the pelvic structures is common, and many may have pessaries to aid in treatment. References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/

Author: Michael Hunt, M.D. Educational Pearls: Children under age of 6 are at greatest risk of accidental nicotine overdose from ingestion. Biphasic presentation: Hyperadrenergic = nausea, vomiting, tachycardia, flushing. Bradycardia and respiratory depression. References: http://www.aapcc.org/alerts/e-cigarettes/ Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology. 2013;88(1):5-7. doi:10.1007/s00204-013-1127-0.

Author: Jared Scott M.D. Educational Pearls: Bear mauling is not a common issue in the ED. The Ursus americanus (black bear) is the most common in Colorado, but Ursus arctos horribilis (grizzly bear) attacks are more frequent because they are more aggressive. Head and neck lacerations are the most common injuries. Complications include infection and long term PTSD. Most bear attacks are defensive in nature. If a bear attacks you - lay face down and cover your neck with your hands. References: Frank RC, Mahabir RC, Magi E, Lindsay RL, de Haas W. Bear maulings treated in Calgary, Alberta: Their management and sequelae. The Canadian Journal of Plastic Surgery. 2006;14(3):158-162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539044/

Author: Sam Killian, M.D. Educational Pearls: "The Rabbit Has Died" is a lesser used phrase to denote finding out one is pregnant. During a test used in the 1930s, the "Rabbit's Test," a rabbit was injected with a potentially pregnant woman's urine. If the woman was pregnant, the rabbit would begin displaying signs of pregnancy itself. This test required killing the rabbits to visualize the ovaries, hence the term "Rabbit Done Died". References: https://www.early-pregnancy-tests.com/history

Author: Martin O'Bryan M.D. Educational Pearls: Vocal cord dysfunction can mimic other causes of stridor, such as asthma and upper airway obstruction. Patients are often very anxious because of the difficulty of inspiration. The definitive diagnosis is laryngoscopy that must be done by a pulmonologist. The treatment is general reassurance, asthma medications will not help. CPAP and heliox can be used to help with the stridor. Benzodiazepines can be used to reduce the associated anxiety. References: https://asthmarp.biomedcentral.com/articles/10.1186/s40733-015-0009-z