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2 View: Emergency Medicine PAs & NPs
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2 View: Emergency Medicine PAs & NPs

Author: The Center for Medical Education

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The 2 View is a podcast featuring EM clinicians Martha Roberts NP and Michael Sharma PA. The podcast discusses hot topics in EM and urgent care for advanced practice providers. The podcasts features literature reviews, case studies, controversial topics, and innovative approaches to the emergent and urgent care patient.
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The 2 View: Episode 6

The 2 View: Episode 6

2021-06-1401:27:25

Welcome to Episode 6 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 6 of “The 2 View” Lyme Disease Arumugam S, Nayak S, Williams T, et al. A Multiplexed Serologic Test for Diagnosis of Lyme Disease for Point-of-Care Use. J Clin Microbiol. Published November 22, 2019. Accessed June 1, 2021. https://journals.asm.org/doi/full/10.1128/JCM.01142-19 Gastroparesis Camilleri, M. MD. Gastroparesis: Etiology, Clinical Manifestations, and Diagnosis. Uptodate.com. Updated September 30, 2020. Accessed June 1, 2021. https://www.uptodate.com/contents/gastroparesis-etiology-clinical-manifestations-and-diagnosis?search=gastroparesis§ionRank=1&usagetype=default&anchor=H859989&source=machineLearning&selectedTitle=2~150&displayrank=2 Center for Drug Evaluation, Research. How to Request Domperidone for Expanded Access Use. Fda.gov. Published February 2, 2021. Accessed June 1, 2021. https://www.fda.gov/drugs/investigational-new-drug-ind-application/how-request-domperidone-expanded-access-use Gastroparesis. American College of Gastroenterology. Updated December 2012. Accessed June 1, 2021. https://gi.org/topics/gastroparesis/ Gastroparesis - NORD (national organization for rare disorders). Rarediseases.org. Published February 11, 2015. Accessed June 1, 2021. https://rarediseases.org/rare-diseases/gastroparesis/ Spiked Helmet EKG Sign: See full show notes here: https://bit.ly/3xaCoga Career Advancements: Side Gigs & Moving Up in the Workforce Passive Income. The List of Physician Side Hustles. Passiveincomemd.com. Published February 4, 2020. Accessed June 1, 2021. https://passiveincomemd.com/list-physician-side-hustles/ Shemmassian. 14 Physician Side Gigs to Accelerate Your Income — Shemmassian Academic Consulting. Shemmassianconsulting.com. Published March 26, 2020. Accessed June 1, 2021. https://www.shemmassianconsulting.com/blog/physician-side-gigs Sitar, D. 11 Side Gigs You Can Do Entirely from Home. Thepennyhoarder.com. Published July 7, 2020. Accessed June 1, 2021. https://www.thepennyhoarder.com/make-money/side-gigs/work-from-home-coronavirus/ Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding needlestick safety and prevention – who was the President of the United States that signed the Needlestick Safety and Prevention Act into law and who was the Massachusetts nurse whose advocacy for sharps injury safety helped the act pass and who later became president of the American Nurses Association? The correct answer was President Bill Clinton and Karen Daley, PhD, MPH, RN, FAAN. Please note that for this month, if you get the trivia question correct, you will win your course registration to one of our LIVE EM Boot Camp Courses, available in July and November of this year! It’s a great course so be sure to download and listen to the episode for the question! Please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.
The 2 View: Episode 5

The 2 View: Episode 5

2021-05-1301:18:10

Welcome to Episode 5 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Full show notes for Episode 5 of “The 2 View” can also be found here: https://docs.google.com/document/d/1zcY2AKac2_5xxSwwubIgkypWkRI-uRit9zuIvqDpPLY/edit?usp=sharing Needle Sticks Needlestick Helpline: If you have questions about appropriate medical treatment for occupational exposures, assistance is available from the Clinicians’ Post Exposure Prophylaxis (PEP) Line at 1-888-448-4911. National Clinician Consultation Center. Ucsf.edu. Accessed April 22, 2021. https://nccc.ucsf.edu/ Moayedi, Siamak MD, Torres, Mercedes MD. HIV Post-Exposure Prophylaxis. EM:RAP CorePendium. Emrap.org. Updated October 5, 2020. Accessed April 22, 2021. https://www.emrap.org/corependium/chapter/rech6mbrZTyKtAIqw/HIV-Post-Exposure-Prophylaxis Roberts, Martha ACNP, CEN. Viewpoint: A Needle Stick and a Life Lesson. Emergency Medicine News. Lww.com. Updated December 2015. Accessed April 22, 2021. https://journals.lww.com/em-news/Fulltext/2015/12000/Viewpoint_ANeedleStickandaLife_Lesson.19.aspx Announcement: Updated Guidelines for Antiretroviral Postexposure Prophylaxis after Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV — United States, 2016. Morbidity and Mortality Weekly Report (MMWR). Cdc.gov. Updated May 6, 2016. Accessed April 22, 2021. https://www.cdc.gov/mmwr/volumes/65/wr/mm6517a5.htm U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep. 2001;50(RR-11):1-52. Cdc.gov. Updated June 29, 2001. Accessed April 22, 2021. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm Dominguez KL, Smith DK, Thomas V, et al. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. Cdc.gov. Updated May 23, 2018. Accessed April 22, 2021. https://stacks.cdc.gov/view/cdc/38856 Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(1):1-31. Cdc.gov. Updated January 12, 2018. Accessed April 22, 2021. https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm CDC - Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, Hepatitis C - Emergency Needlestick Information - NIOSH Workplace Safety and Health Topic. Cdc.gov. Published November 21, 2018. Accessed April 22, 2021. https://www.cdc.gov/niosh/topics/bbp/emergnedl.html Hepatitis C Questions and Answers for Health Professionals. Cdc.gov. Published April 9, 2021. Accessed April 22, 2021. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm Hepatitis B Foundation: Understanding Your Hepatitis B Test Results. Hepb.org. Accessed April 22, 2021. https://www.hepb.org/prevention-and-diagnosis/diagnosis/understanding-your-test-results/ Procedures: The Top Ten in EM Right Now Roberts M, Roberts JR. The Proceduralist. Accessed April 22, 2021. https://www.theproceduralist.org/ The Proceduralist. Youtube.com. Accessed April 22, 2021. https://www.youtube.com/channel/UCQtZPVvIl2tCJdNrslXcCww Back Pain Featuring W. Richard Bukata, M.D. Motov, Sergey. Faculty Forum: A Practical Approach to Pain Management. YouTube. https://www.youtube.com/watch?v=lJSioPsGw3A. The Center for Medical Education. Published December 2, 2020. Accessed April 22, 2021. @painfreeED LaFollette R. Back to Basics: Treatment of Acute Low Back Pain in the ED — Taming the SRU. Emergency Medicine Tamed. Tamingthesru.com. Published August 31, 2020. Accessed April 22, 2021. https://www.tamingthesru.com/blog/diagnostics/back-pain Della-Giustina D. Evaluation and treatment of acute back pain in the emergency department. Emerg Med Clin North Am. 2015;33(2):311-326. Published May 2015. Accessed April 22, 2021. https://pubmed.ncbi.nlm.nih.gov/25892724/ Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med. 2015;66(2):148-153. 2015. Accessed April 22, 2021. https://www.annemergmed.com/article/S0196-0644(14)01509-1/pdf Recurring Sources Center for Medical Education. Ccme.org. Accessed April 22, 2021. http://ccme.org The Skeptics Guide to Emergency Medicine. Thesgem.com. Accessed April 22, 2021. http://www.thesgem.com The Proceduralist. Theproceduralist.org. Accessed April 22, 2021. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. Accessed April 22, 2021. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx *Here are just a few links we mentioned in the podcast. This is a small taste of the 100's of videos and blogs we have on procedures. Be sure to check out the FULL library of videos and blogs on the blog site, The Procedural Pause. For new blogs and more, you can check out our new site, The Proceduralist! Procedure: Slit Lamp Exam - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=89 Procedure: Cerumen Impaction - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=109 Procedures: Ear Wicks - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=105 Procedure: Ankle relocations and splinting - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=90 Procedure: Some lower leg splinting - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=73 Procedure: Tonometry - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=86 Procedure: TXA / Epistaxis - https://www.youtube.com/watch?v=vx0nPnkJK44 Procedure: Lumbar Puncture (Part I in a series) - https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=20 Procedure: Central Line Tie Down - https://www.youtube.com/watch?v=JyDjU3O_bNA Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding sickle cell disease – we know why it’s called sickle cell disease, but who were the two people who discovered why the red blood cells become a sickled shape? Desi Spellings, FNP-C from Memphis, Tennessee gave us the correct answer of E. Vernon Hahn and Elizabeth Gillespie. Be sure to cash in your prize – you can email meghan@ccme.org to get your course at 20% off. Please note that for this month, if you get the trivia question correct, you will win 20% off any CCME course you want. That’s right, ANY CCME course you want, including live courses. You can buy it for yourself or give it to a friend - it’s your 20% off. So, download and listen to the episode for the question! Please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.
The 2 View: Episode 4

The 2 View: Episode 4

2021-04-1101:06:33

Welcome to Episode 4 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Full show Notes for Episode 4 of “The 2 View” can be found here: https://docs.google.com/document/d/1Awc9VPm2igzhKwNoDO07eq269bZTgrPtfSCJVVCvu6U/edit?usp=sharing Sickle Cell Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020;4(12):2656-2701. Accessed April 5, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322963/ Della-Moretta S, Delatore L, Purcell M, et al. The Effect of Use of Individualized Pain Plans in Sickle Cell Patients Presenting to the Emergency Department. Ann Emerg Med. Published September 2020. Accessed March 17, 2021. https://www.sciencedirect.com/science/article/pii/S019606442030648X Table from Cisewski D. ED Management of Sickle Cell Vaso-occlusive Crises: Myths, Facts, and A Novel Approach to Acute Pain Management. emDocs. Updated April 15, 2019. Accessed April 5, 2021. https://www.emdocs.net/ed-management-of-sickle-cell-vaso-occlusive-crises-myths-facts-and-a-novel-approach-to-acute-pain-management/ A Practical Approach to Pain Management in the Acute Care Setting with Dr. Sergey Motov, MD / EM Boot Camp Faculty Forum #2. Updated December 2, 2020. Accessed April 5, 2021. https://youtu.be/lJSioPsGw3A Sickle Cell Disease. CorePendium. EM:RAP.org, 2020. Updated December 7, 2020. Accessed April 5, 2021. https://www.emrap.org/corependium/chapter/recZWicqx0K20uwsz/Sickle-Cell-Disease Procedure IM Shots Roberts M, Roberts JR. Intramuscular Injections: 101 — The Proceduralist. The Proceduralist. Accessed March 17, 2021. https://www.theproceduralist.org/thecases/intramusclar-injections-101 You Call the Shots – Vaccine Administration: Intramuscular (IM) Injection Adults 19 years of age and older. Cdc.gov. Published November 16, 2020. Accessed March 17, 2021. https://www.cdc.gov/vaccines/hcp/admin/downloads/IM-Injection-adult.pdf Documentation Henry, Greg, MD. What You Must Know to Avoid Being Sued. Original Emergency Medicine Boot Camp. December 2019. Las Vegas. Accessed March 17, 2021. Risk Management Monthly. The Center for Medical Education. Accessed March 17, 2021. https://www.ccme.org/riskmgmt/ Weinstock MB; Longstreth R; Henry GL. Bouncebacks! Emergency Department Cases: ED Returns. 2nd ed. Anadem; 2018. First Time Seizures Epilepsy. American Association of Neurological Surgeons. Accessed March 17, 2021. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Epilepsy Types of Seizures. Johns Hopkins Medicine. Accessed March 17, 2021. https://www.hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/types-of-seizures Billet, M MD, Khouja, D MBBS. Seizures in Adults. EM:RAP CorePendium. Emrap.org. Updated September 15, 2020. Accessed March 17, 2021. https://www.emrap.org/corependium/chapter/recLTpXKGatE7jq2r/Seizures-in-Adults Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ. Published February 11, 2006. Accessed March 17, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1363913/ Adamolekun, B MD. Seizure Disorders. Merck Manuals. Content last modified July 2020. Accessed March 17, 2021. https://www.merckmanuals.com/professional/neurologic-disorders/seizure-disorders/seizure-disorders Neurology. American Academy of Neurology. Accessed March 17, 2021. https://n.neurology.org/ Ho K, Lawn N, Bynevelt M, Lee J, Dunne J. Neuroimaging of first-ever seizure: Contribution of MRI if CT is normal. Neurol Clin Pract. Published October 2013. Accessed March 17, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765827/ First Time Seizure. Emrap.org. Published August 2017. Accessed March 17, 2021. https://www.emrap.org/episode/c3seizures/seizuresfirst Trivia Question: Send answers to 2viewcast@gmail.com Please note that for this month, if you get the trivia question correct, you will win 20% off any CCME course you want. That’s right, ANY CCME course you want, including live courses. You can buy it for yourself or give it to a friend - it’s your 20% off. So, download and listen to the episode for the question! Please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.
The 2 View: Episode 3

The 2 View: Episode 3

2021-03-1101:02:02

Welcome to episode 3 of The 2 View, the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 3 of The 2 View Pancreatitis Mederos MA, Reber HA, Girgis MD. Acute Pancreatitis: A Review. JAMA. Published January 26, 2021. Accessed February 3, 2021. https://jamanetwork.com/journals/jama/article-abstract/2775452 Besinger, B, Stehman, C. Pancreatitis and Cholecystitis. McGraw-Hill Medical. Accessed February 3, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=189593288 Singh VK, Wu BU, Bollen TL, et al. Early Systemic Inflammatory Response Syndrome is Associated with Severe Acute Pancreatitis. Clin Gastroenterol Hepatol. Published 2009. Accessed February 3, 2021. https://www.cghjournal.org/article/S1542-3565(09)00774-5/pdf#:~:text=Second%2C%20patients%20with%203%20or,care%2C%20and%2013%25%20died. Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg. Published June 2006. Accessed February 3, 2021. https://pubmed.ncbi.nlm.nih.gov/16671062/ Murali, N. Pancreatic Disease. EM:RAP CorePendium. Emrap.org. Updated January 13, 2021. Accessed February 3, 2021. https://www.emrap.org/corependium/chapter/recNUBEcCXS86j9qX/Pancreatic-Disease Cast Cutter Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed February 3, 2021. Frosch, D, Knott, P. Cast Cutter. ScienceDirect. Published 2007. Accessed February 3, 2021. https://www.sciencedirect.com/topics/nursing-and-health-professions/cast-cutter Questions Local Reactions, Systemic Reactions, Adverse Events, and Serious Adverse Events: Pfizer-BioNTech COVID-19 Vaccine. Cdc.gov. Published January 14, 2021. Accessed February 3, 2021. https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/reactogenicity.html Local Reactions, Systemic Reactions, Adverse Events, and Serious Adverse Events: Moderna COVID-19 Vaccine. Cdc.gov. Published December 22, 2020. Accessed February 3, 2021. https://www.cdc.gov/vaccines/covid-19/info-by-product/moderna/reactogenicity.html Information on COVID-19 treatment, prevention and research. Nih.gov. Accessed February 3, 2021. https://www.covid19treatmentguidelines.nih.gov/ Targett C, Harris T. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 3: Can metronomes improve CPR quality? Emerg Med J. Published 2014. Accessed February 3, 2021. https://emj.bmj.com/content/31/3/251 Headaches/Migraine Volpi-Abadie J, Kaye AM, Kaye AD. Serotonin Syndrome. Ochsner J. Published Winter 2013. Accessed February 3, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865832/ Roberts, J. InFocus: The Best Three Treatments for Migraine. Emergency Medicine News. Published January 2018. Accessed February 3, 2021. https://journals.lww.com/em-news/Fulltext/2018/01000/InFocus_TheBestThreeTreatmentsforMigraine.8.aspx Roberts, J. InFocus: The Miserable, Misunderstood Migraine. Emergency Medicine News. Published December 2017. Accessed February 3, 2021. https://journals.lww.com/em-news/Fulltext/2017/12000/InFocus_TheMiserable,MisunderstoodMigraine.8.aspx Your resource for headache info. Americanheadachesociety.org. Published May 17, 2016. Accessed February 3, 2021. https://americanheadachesociety.org/
The 2 View: Episode 2

The 2 View: Episode 2

2021-02-0358:34

View the full show notes on Google Docs here: http://bit.ly/3cpvlJc 2020 BLS/ACLS Guideline Changes Merchant RM, Topjian AA, Panchal AR, et al. Part 1: Executive summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Published October 21, 2020. Accessed January 20, 2021. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000918 Highlights of the 2020 American Heart Association Guidelines for CPR and ECC. American Heart Association. Published 2020. Accessed January 20, 2021. https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts2020eccguidelinesenglish.pdf Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get with The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. Published April 9, 2020. Accessed January 20, 2021. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.120.047463 Topjian A, Aziz K, Kamath-Rayne BD, et al. Interim Guidance for Basic and Advanced Life Support in Children and Neonates with Suspected or Confirmed COVID-19. Pediatrics. Published 2020. Accessed January 20, 2021. https://pediatrics.aappublications.org/content/early/2020/04/13/peds.2020-1405 Hunt EA, Jeffers J, McNamara L, et al. Improved Cardiopulmonary Resuscitation Performance with CODE ACES2: A Resuscitation Quality Bundle. Journal of the American Heart Association. Published December 7, 2018. Accessed January 20, 2021. https://www.ahajournals.org/doi/10.1161/JAHA.118.009860 Procedural Pearl of the Month - Fish Hooks Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed January 20, 2021. The Procedural Pause by James R. Roberts, MD, & Martha Roberts, ACNP, PNP. Fishing Out the Fishhook. Emergency Medicine News. Published September 1, 2020. Accessed January 20, 2021. https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=108 Droperidol DeFranco, C, DO. Oldie but a Goodie: 10 Pearls of Droperidol. Acep.org. Published 2021. Accessed January 20, 2021. https://www.acep.org/how-we-serve/sections/pain-management/news/may-2020/oldie-but-a-goodie-10-pearls-of-droperidol/ Ho, J, FAAEM MD, Perkins J, FAAEM MD. Clinical Practice Statement: Safety of Droperidol Use in the Emergency Department. Aaem.org. Published September 7, 2013. Accessed January 20, 2021. https://www.aaem.org/UserFiles/file/Safety-of-Droperidol-Use-in-the-ED.pdf Cisewski, D MD. Droperidol Use in the Emergency Department – What’s Old is New Again. Emdocs.net. Published August 1, 2019. Accessed January 20, 2021. http://www.emdocs.net/droperidol-use-in-the-emergency-department-whats-old-is-new-again/ Ken’s Third View SGEM#315: Comfortably Numb with Topical Tetracaine for Corneal Abrasions. Thesgem.com. Published January 16, 2021. Accessed January 20, 2021. http://thesgem.com/2021/01/sgem315-comfortably-numb-with-topical-tetracaine-for-corneal-abrasions/ Shipman S, Painter K, Keuchel M, Bogie C. Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Ann Emerg Med. Published October 27, 2020. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/33121832/ SGEM#316: What A Difference an A.P.P. Makes? Diagnostic Testing Differences Between A.P.P.S and Physicians. Thesgem.com. Published January 23, 2021. Accessed January 24, 2021. http://thesgem.com/2021/01/sgem316-what-a-difference-an-a-p-p-makes-diagnostic-testing-differences-between-a-p-p-s-and-physicians/ Pines JM, Zocchi MS, Ritsema TS, Bedolla J, Venkat A, US Acute Care Solutions Research Group. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. Acad Emerg Med. Published November 21, 2020. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/33107088/ Gonorrhea Questions Answered Scully BE, Fu KP, Neu HC. Pharmacokinetics of ceftriaxone after intravenous infusion and intramuscular injection. Am J Med. Published October 19, 1984. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/6093511/ Meyers BR, Srulevitch ES, Jacobson J, Hirschman SZ. Crossover study of the pharmacokinetics of ceftriaxone administered intravenously or intramuscularly to healthy volunteers. Antimicrob Agents Chemother. Published November 1983. Accessed January 20, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC185948/ Shatsky M. Evidence for the use of intramuscular injections in outpatient practice. Am Fam Physician. Published February 15, 2009. Accessed January 20, 2021. https://pubmed.ncbi.nlm.nih.gov/19235496/ Trivia Question: Send answers to 2viewcast@gmail.com Please note that for this month, if you get the trivia question correct, you will win 20% off any CCME course you want. That’s right, ANY CCME course you want. You can buy it for yourself or give it to a friend - it’s your 20% off. So, download and listen to the episode for the question! Please email us your guesses at 2viewcast@gmail.com, that’s the number 2, view, cast @gmail.com and tell us who you want to give a shout-out to.
The 2 View: Episode 1

The 2 View: Episode 1

2021-01-1201:01:19

View the show notes in Google Docs here: http://bit.ly/3bFS43j Gonorrhea Updates Gonorrhea Treatment and Care. Centers for Disease Control and Prevention Website. https://www.cdc.gov/std/gonorrhea/treatment.htm. Published December 14, 2020. Accessed January 11, 2021. CDC No Longer Recommends Oral Drug for Gonorrhea Treatment. Centers for Disease Control and Prevention. https://www.cdc.gov/nchhstp/newsroom/2012/gctx-guidelines-pressrelease.html. Published August 9, 2012. Accessed January 11, 2021. Recurrent UTI Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019). American Urological Association. https://www.auanet.org/guidelines/recurrent-uti?fbclid=IwAR1TwSTQNHv8PDWLfW7WjsDan46D_9b6Qs1ptJxaXr6YFnDpBeptpW3BY. Published 2019. Accessed January 11, 2021. Combo Ibuprofen and Acetaminophen / Pain Advil® Dual Action. GSK Expert Portal. https://www.gskhealthpartner.com/en-us/pain-relief/brands/advil/products/dual-action/?utmsource=google&utmmedium=cpc&utmterm=ibuprofen+acetaminophen&utmcampaign=GS+-+Unbranded+Advil+DA+-+Alone+-+PH. Accessed January 11, 2021. FDA approves GSK's Advil Dual Action with Acetaminophen for over-the-counter use in the United States. GSK. https://www.gsk.com/en-gb/media/press-releases/fda-approves-gsk-s-advil-dual-action-with-acetaminophen-for-over-the-counter-use-in-the-united-states/. Published March 2, 2020. Accessed January 11, 2021. Tanner T, Aspley S, Munn A, Thomas T. The pharmacokinetic profile of a novel fixed-dose combination tablet of ibuprofen and paracetamol. BMC clinical pharmacology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906415/. Published July 5, 2010. Accessed January 11, 2021. Searle S, Muse D, Paluch E, et al. Efficacy and Safety of Single and Multiple Doses of a Fixed-dose Combination of Ibuprofen and Acetaminophen in the Treatment of Postsurgical Dental Pain: Results From 2 Phase 3, Randomized, Parallel-group, Double-blind, Placebo-controlled Studies. The Clinical journal of pain. https://pubmed.ncbi.nlm.nih.gov/32271183/. Published July 2020. Accessed January 11, 2021. 1000 mg versus 600/650 mg Acetaminophen for Pain or Fever: A Review of the Clinical Efficacy. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK373467/. Published June 17, 2016. Accessed January 11, 2021. Motov S. Is There a Limit to the Analgesic Effect of Pain Medications? Medscape. https://www.medscape.com/viewarticle/574279. Published June 17, 2008. Accessed January 11, 2021. Motov, Sergey. Faculty Forum: A Practical Approach to Pain Management. YouTube. https://www.youtube.com/watch?v=lJSioPsGw3A. The Center for Medical Education. Published December 2, 2020. Accessed January 1, 2021. Wuhrman E, Cooney MF. Acute Pain: Assessment and Treatment. Medscape. https://www.medscape.com/viewarticle/735034_4. Published January 3, 2011. Accessed January 11, 2021. Social Pain Dewall CN, Macdonald G, Webster GD, et al. Acetaminophen reduces social pain: behavioral and neural evidence. Psychological science. https://pubmed.ncbi.nlm.nih.gov/20548058/. Published June 14, 2010. Accessed January 11, 2021. Mischkowski D, Crocker J, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Social cognitive and affective neuroscience. https://pubmed.ncbi.nlm.nih.gov/27217114/. Published May 5, 2016. Accessed January 11, 2021. Other / Recurrent liner notes Center for Medical Education. https://courses.ccme.org/. Accessed January 11, 2021. Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed January 11, 2021. The Procedural Pause by James R. Roberts, MD, & Martha Roberts, ACNP, PNP. Emergency Medicine News. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx. Accessed January 11, 2021. The Skeptics' Guide to Emergency Medicine. sgem.ccme.org. https://sgem.ccme.org/. Accessed January 11, 2021. Trivia Question: Send answers to 2viewcast@gmail.com Please note that you must answer the 2 part question to win a copy of the EMRA Pain Guide. “What controversial drug was given a black box warning for prolonged QT and torsades in 2012 and now has been declared by WHICH organization to be an effective and safe treatment use for nausea, vomiting, headache and agitation?” Practical Pain Management in Acute Care Setting Handout Sergey Motov, MD @painfreeED • Pain is one of the most common reasons for patients to visit the emergency department and other acute care settings. Due to the extensive number of visits related to pain, clinicians and midlevel providers should be aware of the various options, both pharmacological and nonpharmacological, available to treat patients with acute pain. • As the death toll from the opioid epidemic continues to grow, the use of opioids in the acute care setting as a first-line treatment for analgesia is becoming increasingly controversial and challenging. • There is a growing body of literature that is advocating for more judicious use of opioids and well as their prescribing and for broader use of non-pharmacological and non-opioid pain management strategies. • The channels/enzymes/receptors targeted analgesia (CERTA) concept is based on our improved understanding of the neurobiological aspect of pain with a shift from a symptom-based approach to pain to a mechanistic approach. This targeted analgesic approach allows for a broader utilization of synergistic combinations of nonopioid analgesia and more refined and judicious (rescue) use of opioids. These synergistic combinations result in greater analgesia, fewer side effects, lesser sedation, and shorter LOS. (Motov et al 2016) General Principles: Management of acute pain in the acute care setting should be patient-centered and pain 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. Brief pain inventory short form BPI-SF is better than NRS/VAS as it assesses quantitative and qualitative impact of pain (Im et al 2020). 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. 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. Non-Pharmacologic Therapies • Acute care providers should consider applications of heat or cold as well as specific recommendations regarding activity and exercise. • Music therapy is a useful non-pharmacologic therapy for pain reduction in acute care setting (music-assisted relaxation, therapeutic listening/musical requests, musical diversion, song writing, and therapeutic singing (Mandel 2019). • The use of alternative and complementary therapies, such as acupuncture, guided imagery, cognitive-behavioral therapy, and hypnosis have not been systemically evaluated for use in the Acute care setting including ED. (Dillan 2005, Hoffman 2007) • In general, their application may be limited for a single visit, but continued investigation in their safety and efficacy is strongly encouraged. • Practitioners may also consider utilization of osteopathic manipulation techniques, such as high velocity, low amplitude techniques, muscle energy techniques, and soft tissue techniques for patients presenting to the acute care setting with pain syndromes of skeletal, arthroidal, or myofascial origins. (Eisenhart 2003) Opioids • Acute Care providers are uniquely positioned to combat the opioid epidemic by thoughtful prescribing of parenteral and oral opioids in inpatient setting and upon discharge, and through their engagement with opioid addicted patients in acute care setting. • Acute Care providers should make every effort to utilize non-pharmacological modalities and non-opioid analgesics to alleviate pain, and to use opioid analgesics only when the benefits of opioids are felt to outweigh the risks. (not routinely) • When opioids are used for acute pain, 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, Acute Care providers 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 considering opioids for acute pain, acute care providers should counsel patients regarding serious adverse effects such as sedation and respiratory depression, pruritus and constipation, and rapid development of tolerance and hyperalgesia. • When considering administration of opioids for acute pain, acute care 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. • PDMPs can provide clinicians with comprehensive prescribing information to improve clinical decisions around opioids. However, PDMPs vary tremendously in their accessibility and usability in the ED, which limits their effectiveness at the point of care. Problems are complicated by varying state-to-state requirements for data availability and accessibility. Several potential solutions to improving the utility of PDMPs in EDs include integrating PDMPs with electronic health records, implementing unsolicited reporting and prescription context, improving PDMP accessibility, data analytics, and expanding the scope of PDMPs. (Eldert et al, 2018) • Parenteral opioids when used in titratable fashion are effective, safe, and easily reversible analgesics that quickly relieve pain. • Acute care clinicians should consider administering these analgesics for patients in acute pain where the likelihood of analgesic benefit is judged to exceed the likelihood of harm. • Parenteral opioids must be titrated regardless of their initial dosing regimens (weight-based or fixed) until pain is optimized to acceptable level (functionality status) or side effects become intolerable. • When parenteral opioids are used, patients should be engaged in shared-decision making regarding the route of administration, as repetitive attempts of IV cannulation and intramuscular injections are associated with pain. In addition, intramuscular injections are associated with unpredictable absorption rates, and complications such as muscle necrosis, soft tissue infection and the need for dose escalation. (Von Kemp 1989, Yamanaka 1985, Johnson 1976) • Morphine sulfate provides better balance of analgesic efficacy and safety among all parenteral opioids. a. Dosing regimens and routes: b. IV: 0.05-0.1mg/kg to start, titrate q 10-20 min c. IV: 4-6 mg fixed, titrate q 10-20 min d. SQ: 4-6 mg fixed, titrate q 20 min e. Nebulized: 0.2 mg/kg or 10-20 mg fixed, repeat q 15-20 min f. PCA: prone to dosing errors g. IM: should be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) • Hydromorphone should be avoided as a first-line opioid due to significant euphoria and severe respiratory depression requiring naloxone reversal. Due to higher lipophilicity, Hydromorphone use is associated with higher rates of euphoria and subsequent development of addiction. Should hydromorphone be administered in higher than equi-analgesic morphine milligram equivalents, close cardiopulmonary monitoring is strongly recommended. Dosing h. IV: 0.2-0.5 mg initial, titrate q10-15 min i. IM: to be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) j. PCA: prone to dosing errors (severe CNS and respiratory depression) k. Significantly worse AE profile in comparison to Morphine l. Equianalgesic IV conversion (1 mg HM=8mg of MS) m. Overprescribed in >50% of patients n. Inappropriately large dosing in EM literature: 2 mg IVP o. Abuse potential (severely euphoric due to lipophilicity) • Fentanyl is the most potent opioid, short-acting, requires frequent titration. Dosing: p. IV: 0.25-0.5 μg/kg (WB), titrate q10 min q. IV: 25-50 μg (fixed), titrate q10 min r. Nebulization: 2-4 μg/kg, titrate q20-30 min s. IN: 1-2 μg/kg, titrate q5-10min t. Transbuccal: 100-200μg disolvable tablets u. Transmucosal: 15-20 mcg/kg Lollypops • Opioids in Renal Insufficiency/Renal Failure Patients-requires balance of ORAE with pain control by starting with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. (Dean 2004, Wright 2011) • Opioid-induced pruritus is centrally mediated process via μ-opioid receptors as naloxone, nalbuphine reverse it, and can be caused by opioids w/o histamine release (Fentanyl). Use ultra-low-dose naloxone of 0.25 -1 mcg/kg/hr with NNT of 3.5. (Kjellberg 2001) • When intravascular access is unobtainable, acute care clinicians should consider utilization of intranasal (fentanyl), nebulized (fentanyl and morphine), or transmucosal (rapidly dissolvable fentanyl tablets) routes of analgesic administration for patients with acute painful conditions. • Breath actuated nebulizer (BAN): enclosed canister, dual mode: continuous and on-demand, less occupational exposures. a. Fentanyl: 2-4 mcg//kg for children, 4 mcg/kg for adults: titration q 10 min up to three doses via breath-actuated nebulizer (BAN): systemic bioavailability of 50-60% of IV route. (Miner 2007, Furyk 2009, Farahmand 2014) b. Morphine: 10-20 mg g10 min up to 3 doses via breath-actuated nebulizer (BAN)-Systemic bioavailability (concentration) of 30-35% of IV Route. (Fulda 2005, Bounes 2009, Grissa 2015) c. Intranasal Fentanyl: IN via MAD at 1-2 mcg/kg titration q 5 min (use highly concentrated solution of 100mcg/ml for adults and 50 mcg/ml for children)- systemic bioavailability of 90% of IV dosing. (Karisen 2013, Borland 2007, Saunders 2010, Holdgate 2010) d. IN route: shorter time to analgesia, titratable, comparable pain relief to IV route, minimal amount of side effects, similar rates of rescue analgesia, great patients and staff satisfaction. Disadvantages: requires highly concentrated solutions that not readily available in the ED, contraindicated in facial/nasal trauma. Oral Opioids • Oral opioid administration is effective for most patients in the acute care setting, however, there is no appreciable analgesic difference between commonly used opioids (oxycodone, hydrocodone and morphine sulfate immediate release (MSIR). • When oral opioids are used for acute pain, the lowest effective dose and fewest number of tablets needed should be prescribed. In most cases, less than 3 days’ worth are necessary, and rarely more than 5 days’ worth are needed. • If painful condition outlasts three-day supply, re-evaluation in health-care facility is beneficial. Consider expediting follow-up care if the patient’s condition is expected to require more than a three-day supply of opioid analgesics. • Only Immediate release (short-acting) formulary are to be prescribed in the acute care setting and at discharge. • Clinicians should not administer or prescribe long-acting, extended-release, or sustained-release opioid formulations, which include both oral and transdermal (fentanyl) medications in the acute care setting. These formulations are not indicated for acute pain and carry a high risk of overdose, particularly in opioid-naïve patients. • Acute care providers should counsel patients about safe medication storage and disposal, as well as the consequences of failure to do this; potential for abuse and misuse by others (teens and young adults), and potential for overdose and death (children and teens). • Oxycodone is no more effective than other opioids (hydrocodone, MSIR). Oxycodone has highest potential for abuse, misuse and diversion as well as increased risks of overdose, addiction and death. Oxycodone should be avoided as a first-line oral opioid for acute pain. ( Strayer 2016) • If still prescribed, lowest dose (5mg) in combination with acetaminophen (lowest dose of 325 mg) should be considered as it associated with less abuse and diversion (in theory). Potential for acetaminophen overdose exist though with combination. • Hydrocodone is three times more prescribed than oxycodone, but three times less used for non-medical purpose. Combo with APAP (Vicodin)-Use lowest effective dose for hydrocodone and APAP (5/325). (Quinn 1997, Adams 2006) • Immediate release morphine sulfate (MSIR) administration is associated with lesser degree of euphoria and consequently, less abuse potential (Wightman 2012). ED providers should consider prescribing Morphine Sulfate Immediate Release Tablets (MSIR) (Wong 2012, Campos 2014) for acute pain due to: o Similar analgesic efficacy to Oxycodone and Hydrocodone o Less euphoria (less abuse potential) o Less street value (less diversion) o More dysphoria in large doses o Less abuse liability and likeability • Tramadol should not be used in acute care setting and at discharge due to severe risks of adverse effects, drug-drug interactions, and overdose. There is very limited data supporting better analgesic efficacy of tramadol in comparison to placebo, or better analgesia than APAP or Ibuprofen. Tramadol dose not match analgesic efficacy of traditional opioids. (Juurlink 2018, Jasinski 1993, Babalonis 2013) • Side effects are: o Seizures o Hypoglycemia o Hyponatremia o Serotonin syndrome o Abuse and addiction • Codeine and Codeine/APAP is a weak analgesic that provides no better pain relief than placebo. Codeine must not be administered to children due to: o dangers of the polymorphisms of the cytochrome P450 iso-enzyme: o ultra-rapid metabolizers: respiratory depression and death o poor metabolizers: absent or insufficient pain relief • Transmucosal fentanyl (15 and 20 mcg/kg lollypops) has an onset of analgesia in 5 to 15 minutes with a peak effect seen in 15 to 30 minutes (Arthur 2012). • Transbuccal route can be used right at the triage to provide rapid analgesia and as a bridge to intravenous analgesia in acute care setting. (Ashburn 2011). A rapidly dissolving trans-buccal fentanyl (100mcg dose) provides fast pain relief onset (median 10 min), great analgesics efficacy, minimal need for rescue medication and lack of side effects in comparison to oxycodone/acetaminophen tablet (Shear 2010) • Morphine Milligram Equivalent (MME) is a numerical standard against which most opioids can be compared, yielding a comparison of each medication’s potency. MME does not give any information of medications efficacy or how well medication works, but it is used to assess comparative potency of other analgesics. • By converting the dose of an opioid to a morphine equivalent dose, a clinician can determine whether a cumulative daily dose of opioids approaches an amount associated with increased risk of overdose and to identify patients who may benefit from closer monitoring, reduction or tapering of opioids, prescribing of naloxone, and other measures to reduce risk of overdose. • Opioid-induced hyperalgesia: o opioid-induced hyperalgesia (OIH) is a rare syndrome of increasing pain, often accompanied by neuroexcitatory effects, in the setting of increasing opioid therapy. o Morphine is by far the most common opiate implicated in OIH. Hydromorphone and oxycodone, members of the same class of opiate as morphine (phenanthrenes), can also cause OIH. Fentanyl, a synthetic opioid in the class of phenylpiperidine, is less likely to precipitate OIH. Existing data suggests that OIH is caused by multiple opioid-induced changes to the central nervous system including: -Activation of N-methyl-D-aspartate (NMDA) receptors -Inhibition of the glutamate transporter system -Increased levels of the pro-nociceptive peptides within the dorsal root ganglia -Activation of descending pain facilitation from the rostral ventromedial medulla -Neuroexcitatory effects provoked by metabolites of morphine and hydromorphone • OIH can be confused with tolerance as in both cases patients report increased pain on opioids. The two conditions can be differentiated based on the patient’s response to opioids. In tolerance, the patient’s pain will improve with dose escalation. In OIH, pain will worsen with opioid administration. This paradoxical effect is one of the hallmarks of the syndrome. Non-opioid analgesics • Acetaminophen is indicated for management of mild to moderate pain and as a single analgesic and has modest efficacy at most. Addition of Acetaminophen to Ibuprofen does not provide better analgesia for patients with acute low back pain. The greatest limitation to the use of intravenous (IV) versus oral acetaminophen is the nearly 100-fold cost differential, which is likely not justified by any marginal improvement in pain relief. Furthermore, IV APAP provide faster onset of analgesia only after an initial dose. (Yeh 2012, Serinken 2012) • NSAIDs should be administered at their lowest effective analgesic doses both in the ED and upon discharge and should be given for the shortest appropriate treatment course. Caution is strongly advised when NSAIDs are used in patients at risk for renal insufficiency, heart failure, and gastrointestinal hemorrhage, as well as in the elderly. Strong consideration should be given to topical NSAID’s in managing as variety of acute and chronic painful Musculo-skeletal syndromes. The analgesic ceiling refers to the dose of a drug beyond which any further dose increase will not result in additional analgesic efficacy. Thus, the analgesics ceiling for ibuprofen is 400 mg per dose (1200 mg/24 h) and for ketorolac is 10 mg per dose (10 mg/24 h). These doses are less than those often prescribed for control of inflammation and fever. When it comes to equipotent doses of different NSAIDs, there is no difference in analgesic efficacy. • Ketamine, at sub-dissociative doses (also known as low-dose ketamine or analgesic dose ketamine) of 0.1 to 0.4 mg/kg, provided effective analgesia as a single agent or as an adjunct to opioids (reducing the need for opioids) in the treatment of acute traumatic and nontraumatic pain in the ED. This effective analgesia, however, must be balanced against high rates of minor adverse side effects (14%–80%), though typically short-lived and not requiring intervention. In addition to IV rout, ketamine can be administered via IN,SQ, and Nebulized route. • Local anesthetics are widely used in the ED for topical, local, regional, intra-articular, and systemic anesthesia and analgesia. Local anesthetics (esters and amides) possess analgesic and anti-hyperalgesic properties by non-competitively blocking neuronal sodium channels. o Topical analgesics containing lidocaine come in patches, ointments, and creams have been used to treat pain from acute sprains, strains, and contusions as well as variety of acute inflammatory and chronic neuropathic conditions, including postherpetic neuralgia (PHN), complex regional pain syndromes (CRPS) and painful diabetic neuropathy (PDN). o UGRA used for patients with lower extremity fractures or dislocations (eg, femoral nerve block, fascia iliaca compartment block) demonstrated significant pain control, decreased need for rescue analgesia, and first-attempt procedural success. In addition, UGRA demonstrated few procedural complications, minimal need for rescue analgesia, and great patient satisfaction. o Analgesic efficacy and safety of IV lidocaine has been evaluated in patients with renal colic and acute lower back pain. Although promising, this therapy will need to be studied in larger populations with underlying cardiac disease before it can be broadly used. o knvlsd • Antidopaminergic and Neuroleptics are frequently used in acute care settings for treatment of migraine headache, chronic abdominal pain, cannabis-induced hyperemesis. • Anti-convulsant (gabapentin and pregabalin) are not recommended for management of acute pain unless pain is of neuropathic origin. Side effects, particularly when combined with opioids (potentiation of euphoria and respiratory depression), titration to effect, and poor patients’ compliance are limiting factors to their use. (Peckham 2018) References: Chang HY, Daubresse M, Kruszewski SP, et al. 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