Topics in this EM Quick Hits podcast
Anand Swaminathan on a simple approach to status epilepticus (0:31)
David Juurlink on codeine and tramadol interactions: nasty drugs with nastier drug interactions (8:37)
Brit Long on DOACS in patients with malignancy: which patient’s with cancer can be safely prescribed DOACs? (13:05)
Ian Stiell on atrial fibrillation rate vs rhythm control controversy (20:55)
Justin Morgenstern on peripheral vasopressors: safe or unsafe? (26:39)
Michelle Klaiman on motivational interviewing that makes a difference to patient’s lives (33:56)
Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brit Long, Michelle Klaiman, Taryn Lloyd, Justin Morgenstern, and Sucheta Sinha, edited by Anton Helman
Cite this podcast as: Helman, A. Swaminathan, A. Juurlink, D. Long, B. Stiell, I. Morgenstern, J. Klaiman, M. Lloyd, T. EM Quick Hits 7 – Status Epilepticus, Codeine Interactions, Anticoagulants in Malignancy, Atrial Fibrillation rate vs rhythm control, Peripheral Vasopressors, Motivational Interviewing. Emergency Medicine Cases. August, 2019. https://emergencymedicinecases.com/em-quick-hits-august-2019/. Accessed [date].
Simplified approach to status epilepticus
Status Epilepticus: Any seizure lasting greater than five minutes including recurrent seizures that add up to five minutes without return to baseline consciousness.
Why it is bad? Prolonged seizure can lead to acidosis causing CV collapse and brain damage.
Step 1: Manage your ABC–DEFG – and Don’t Ever Forget the Glucose!
- Can consider giving glucose empirically vs a quick point of care check
- Get IV access with stat electrolytes on VBG to rule out hyponatremia
- Do a cursory history – think about the possibility of pre-eclampsia, which will require IV magnesium
- Get your airway equipment ready, though often do not need to rush to manage the airway
Step 2: Benzodiazepines are first line
- Call for two doses of benzodiazepine so you have the second dose ready to go
- The most important determinant of stopping the seizure is time to first benzodiazepine dose – in a patient without IV access do not waste time. Give IM midazolam
- Give ample doses: midazolam 0.15mg/kg IV or IM (about 10 mg) or lorazepam 0.1mg/kg (about 7mg)
- If the seizure does not stop within a couple of minutes, give your second dose
Step 3: If benzos fail, propofol comes next
- RSI with propofol – can add ketamine and have norepinephrine on hand for potential hypotension
Step 4: Traditional anti-epileptic
- Post intubation start your traditional antiepileptic; this can be fosphenytoin, phenytoin, or keppra.
- Consider magnesium for pre-eclampsia, hypertonic saline for hyponatremia, and bicarbonate for TCA overdose.
Step 5: Get the patient to a place where an EEG can be placed to ensure there are no subclinical seizures
Tramadol and codeine drug interactions: Nasty drugs with nastier drug interactions
- 90-93% of caucasian people have the enzymes that allows conversion from the prodrugs codeine or tramadol to an effective opioid for analgesia
- If a patient is taking medications that inhibit the CYP 2D6 enzyme such as SSRIs, bupropion or amiodarone, the codeine or tramadol may not be converted adequately to an effective opioid, and as a result the analgesic effects will be diminished or blocked.
- In patients already taking tramadol or codeine, the addition of CYP 2D6-inhibiting drug such as SSRIs, bupropion or amiodarone may abolish the conversion of these analgesics to their effective opioid form, which may precipitate opioid withdrawal
- In the Drugs that Work and Drugs that Don’t episode, we also learned that tramadol is no more effective than acetaminophen or NSAIDs, has highly unpredictable analgesic effects, and may have a higher addiction potential than other opioids.
- Knisely MR, Carpenter JS, Draucker CB, et al. CYP2D6 drug-gene and drug-drug-gene interactions among patients prescribed pharmacogenetically actionable opioids. Appl Nurs Res. 2017;38:107-110.
- Lynch T, Price A. The effect of cytochrome P450 metabolism on drug response, interactions, and adverse effects. Am Fam Physician. 2007;76(3):391-6.
- Frost DA, Soric MM, Kaiser R, Neugebauer RE. Efficacy of Tramadol for Pain Management in Patients Receiving Strong Cytochrome P450 2D6 Inhibitors. Pharmacotherapy. 2019;39(6):724-729.
- Edwards JE, McQuay HJ, Moore RA. Combination analgesic efficacy: individual patient data meta-analysis of single-dose oral tramadol plus acetaminophen in acute postoperative pain. Journal of pain and symptom management. 2002; 23(2):121-30.
- Toupin April K, Bisaillon J, Welch V, Maxwell LJ, Jüni P, Rutjes AWS, Husni M, Vincent J, El Hindi T, Wells GA, Tugwell P. Tramadol for osteoarthritis. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD005522.
DOACs in patients with cancer
- Cancer patients are at 4-7 times increased risk of venous thromboembolism (VTE) compared to other populations, but they also have increased risk of bleeding with 18% of cancer patients having major bleeding, often in the GI tract.
- DOACs are increasingly used for VTE anticoagulation; in cancer patients with newly diagnosed VTE, prior studies have found DOACS comparable to standard anticoagulation but with a controversial increased risk of major bleeding.
- A 2019 meta-analysis suggests an NNT of 41 for preventing recurrent VTE with DOACs in cancer patients. While RCTs suggested increased bleeding, subgroup analysis with rivaroxaban did not.
- Guidelines differ in their recommendations; the ACCP and ASCO recommend LMWH for VTE in cancer patients, while the NCCN and International Society on Thrombosis and Haemostasis prefer DOACs.
- Use shared decision making and discuss with oncology/hematology regarding DOAC use on a case by case basis.
- Thrombosis experts agree that DOACs are a reasonable anticoagulation choice for both atrial fibrillation stroke prophylaxis and treatment of thromboembolic disease in all cancer patients except those with GI malignancies due to the increased risk of GI bleeding.
Bottom line: When it comes to DOACs in cancer patients, they are generally safe but should be avoided in those with GI malignancy.
- Raskob GE, van Es N, Verhamme P, et al. Edoxaban for the treatment of cancer-associated venous thromboembolism. N Engl J Med 2018; 378:615
- Dong Y, Wang Y, Ma RL, et al. Efficacy and safety of direct oral anticoagulants versus low-molecular-weight heparin in patients with cancer: a systematic review and meta-analysis. J Thromb Thrombolysis.2019 May 6. doi: 10.1007/s11239-019-01871-4
- Kearon C,Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. 2016 Feb;149(2):315-35
- Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189–204.
- Streiff MB,Holmstrom B, Angelini D, et al. NCCN Guidelines Insights: Cancer-Associated Venous Thromboembolic Disease, Version 2.2018. J Natl Compr Canc Netw. 2018 Nov;16(11):1289-1303.
- Khorana AA, Noble S, Lee AYY, et al Role of direct oral anticoagulants in the treatment of cancer-associated venous thromboembolism: guidance from the SSC of the ISTH. J Thromb Haemost. 2018;16:1891–1894.
Atrial Fibrillation Rate vs Rhythm Control
- Dr Stiell’s recent RAF2 trial compared two strategies for cardioversion (rhythm control) in acute-onset atrial fibrillation: 1) procainamide infusion + shock vs 2) placebo fluid infusion + shock. Both were similarly effective (>93%) in converting to sinus rhythm and 95% of patients remained in sinus rhythm even 2 weeks afterwards. None of the 396 participants had a stroke.
- Dr. Stiell feels that there is an argument to support rhythm over rate control
- With regards to recent atrial fibrillation guidelines’ suggestion to consider anticoagulating all patients who are cardioverted in the ED for 4 weeks regardless of CHADS-65 score, this suggestion is based on low quality evidence and should be applied on a case by case basis employing shared decision making, patient preference and bleeding risk.
- Stiell, Ian G. et al. Safe Cardioversion for Patients with Acute-Onset Atrial Fibrillation and Flutter: Practical Concerns and Considerations. Canadian Journal of Cardiology. Published online June 13, 2019.
- Andrade JG, Verma A, Mitchell LB, et al. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018;34(11):1371-1392.
- Stiell, I et al. CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist. CJEM 2018;20(3):334-342.
Peripheral vasopressors: Safe or not safe?
- The most common risk with peripheral vasopressors is extravasation which occurs between 2 and 20% depending on the study.
- Tissue necrosis is the most dreaded complication but occurs in <1% of peripheral vasopressor infusions.
- There are also risks with central lines: infections, DVTs, arterial punctures, and prolonged procedure time.
Bottom Line: To decide what is best for your patient, weigh the need for a vasopressor, the risks of running that vasopressor peripherally, and the risks of starting a central line. For most patients, it is reasonable to start the vasopressors peripherally for a short period, as long as the IV is reliable and checked Q1h to look for signs of limb necrosis. If the vasopressors are going to be needed for a prolonged period, a central line should be started whenever it is feasible.
- Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. Journal of hospital medicine. 2015; 10(9):581-5.
- Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. Journal of critical care. 2015; 30(3):653.e9-17.
- Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER) : A Randomized Trial. Am J Respir Crit Care Med. 2019;
- Ricard JD, Salomon L, Boyer A. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Critical care medicine. 2013; 41(9):2108-15.
Other FOAMed resources on peripheral vasopressors
Motivational interviewing part 1: Understanding the power of this evidence based communication skill to enable patients to make meaningful changes to their lives
- Motivational interviewing (MI) is an evidence based counselling technique that helps patients work through ambivalence and empowers them to create behavioural change by eliciting “change talk”. This is more effective than just telling your patient not to do something which can lead to patient resistance and provider frustration and apathy.
Principles and Skills of Motivational Interviewing: RULE OURS mnemonic
- The principles of MI are to Resist the righting reflex, Understand your patient’s motivation, Listen to your patient, and Empower your patient (RULE).
- The basic skills of MI are to use Open ended questions, Affirmations, Reflective listening, and Summaries (OARS).
Readiness ruler of Motivational Interviewing
The readiness ruler is a tool that can be used to elicit change talk that is brief and easy to use in the emergency department setting with three simple questions:
- On a scale of 1-10 how important is it for you to make this change?
- How confident are you to make this change?
- How ready are you to make this change?
Once they have rated themselves on the scale, an example of a follow up MI question includes “Why are you at a 5 and not a 3?” to elicit patient directed discussion of what motivates them to change their behavior.
- Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques – facilitating behaviour change in the general practice setting. Aust Fam Physician. 2012;41(9):660-7.
- Miller, W. R., & Rollnick, S. Motivational interviewing: Helping people change. New York: The Guilford Press. 2013.
- Rosengren, D. B. Building motivational interviewing skills: A practitioner workbook. New York: The Guilford Press. 2018.
None of the authors have any conflicts of interest to declare