Contributor: Aaron Lessen MD Educational Pearls:   Opioid overdoses that are reversed with naloxone (Narcan), a mu-opioid antagonist, can precipitate acute withdrawal in some patients   Treatment of opioid use disorder with buprenorphine can also precipitate withdrawal   Opioid withdrawal symptoms include nausea, vomiting, diarrhea, and agitation   Buprenorphine works as a partial agonist at mu-opioid receptors, which may alleviate withdrawal symptoms    The preferred dose of buprenorphine is 16 mg    Treatment of buprenorphine-induced opioid withdrawal is additional buprenorphine   Adjunctive treatments may be used for other opioid withdrawal symptoms    Nausea with ondansetron   Diarrhea with loperamide   Agitation with hydroxyzine    References 1. Quattlebaum THN, Kiyokawa M, Murata KA. A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine. Fam Pract. 2022;39(2):292-294. doi:10.1093/fampra/cmab073 2. Spadaro A, Long B, Koyfman A, Perrone J. Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. Am J Emerg Med. 2022;58:22-26. doi:10.1016/j.ajem.2022.05.013 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit  

Episode 903: Treating Precipitated Opioid Withdrawal

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting.  Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

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Contributor: Aaron Lessem MD Educational Pearls:    Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza   Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review)    Benefit only occurs if taken within 48 hours of symptom onset   Must be taken for 5 days    A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization    No reduction in hospitalizations with oseltamivir in patients over the age of 12   No difference in high-risk patients over the age of 65 or those with comorbidities    The authors note that the confidence interval in these populations is wide, indicating a need for subsequent studies in high-risk populations     Oseltamivir is associated with adverse effects including nausea, vomiting, and neurologic symptoms    The risk of adverse effects may outweigh the benefits of a small reduction in the duration of illness    References 1. Hanula R, Bortolussi-Courval É, Mendel A, Ward BJ, Lee TC, McDonald EG. Evaluation of Oseltamivir Used to Prevent Hospitalization in Outpatients with Influenza: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024;184(1):18-27. doi:10.1001/jamainternmed.2023.0699 2. Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: Systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348(April):1-18. doi:10.1136/bmj.g2545 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit  

Episode 905: Oseltamivir (Tamiflu) for Influenza

Contributor: Aaron Lessen MD Educational Pearls: Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective? A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question. Methods:   Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine.   The primary outcome was cardiotoxicity   Results:   Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included ischemic EKG changes (2.4%), elevated troponin (1.8%), atrial arrhythmias (1.5%), ventricular arrhythmia (0.3%), and depressed ejection fraction (0.3%).   Affected patients were older, had more comorbidities, and often received multiple epinephrine doses.   Bottom line:   All adults presenting with anaphylaxis should be rapidly treated with epinephrine but monitored closely for cardiotoxicity, especially in patients with a history of hypertension and those who receive multiple doses.   These results are supported by a 2017 study that found that 9% (4/44) of older patients who received epinephrine for anaphylaxis had cardiovascular complications. References   Kawano, T., Scheuermeyer, F. X., Stenstrom, R., Rowe, B. H., Grafstein, E., & Grunau, B. (2017). Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation, 112, 53–58. https://doi.org/10.1016/j.resuscitation.2016.12.020   Pauw, E. K., Stubblefield, W. B., Wrenn, J. O., Brown, S. K., Cosse, M. S., Curry, Z. S., Darcy, T. P., James, T. E., Koetter, P. E., Nicholson, C. E., Parisi, F. N., Shepherd, L. G., Soppet, S. L., Stocker, M. D., Walston, B. M., Self, W. H., Han, J. H., & Ward, M. J. (2024). Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis. Journal of the American College of Emergency Physicians open, 5(1), e13095. https://doi.org/10.1002/emp2.13095   Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit OMS II

Episode 904: Cardiovascular Risks of Epinephrine

Contributor: Travis Barlock MD Educational Pearls: How do you differentiate between compensated and decompensated cirrhosis? Use the acronym VIBE to look for signs of being decompensated.   V-Volume    Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin.   Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen.    I-Infection    The ascitic fluid can become infected with bacteria, a complication called Spontaneous Bacterial Peritonitis (SBP).   Look for abdominal pain, fever, hypotension, and tachycardia. Diagnosis is made with ascitic fluid cell analyses (polymorphonuclear neutrophils >250/mm3)    B-Bleeding    Another consequence of increased portal pressure is that blood backs up into smaller blood vessels, including those in the esophagus.   Over time, this increased pressure can result in the development of dilated, fragile veins called esophageal varices, which are prone to bleeding.   Look for hematemesis, melena, lightheadedness, and pale skin.     E-Encephalopathy    A failing liver also does not clear toxins which can affect the brain.   Look for asterixis (flapping motion of the hands when you tell the patient to hold their hands up like they are going to stop a bus)    Other complications to look out for.   Hepatorenal syndrome   Hepatopulmonary syndrome   References   Engelmann, C., Clària, J., Szabo, G., Bosch, J., & Bernardi, M. (2021). Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. Journal of hepatology, 75 Suppl 1(Suppl 1), S49–S66. https://doi.org/10.1016/j.jhep.2021.01.002   Enomoto, H., Inoue, S., Matsuhisa, A., & Nishiguchi, S. (2014). Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. International journal of hepatology, 2014, 634617. https://doi.org/10.1155/2014/634617   Mansour, D., & McPherson, S. (2018). Management of decompensated cirrhosis. Clinical medicine (London, England), 18(Suppl 2), s60–s65. https://doi.org/10.7861/clinmedicine.18-2-s60   Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMS II  

Episode 902: Liver Failure and Cirrhosis

Contributor: Aaron Lessen MD Educational Pearls:   Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus    Some ED protocols only give 2 mg initially    The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g   In one retrospective study, only 50% of patients received the correct dose of lorazepam    For levetiracetam, it was only 35% of patients    Underdosing leads to complications    Higher rates of intubations   More likely to progress to refractory status epilepticus    References 1. Cetnarowski A, Cunningham B, Mullen C, Fowler M. Evaluation of intravenous lorazepam dosing strategies and the incidence of refractory status epilepticus. Epilepsy Res. 2023;190(November 2022):107067. doi:10.1016/j.eplepsyres.2022.107067 2. Sathe AG, Tillman H, Coles LD, et al. Underdosing of Benzodiazepines in Patients With Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019;26(8):940-943. doi:10.1111/acem.13811 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit  

Episode 903: Treating Precipitated Opioid Withdrawal

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