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 901: Underdosing in Status Epilepticus

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 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

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: Travis Barlock MD Educational Pearls: Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3. Pain dose   For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg).   Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective.   Dissociative dose   To use ketamine as an induction agent for intubation or for procedural sedation administer 1 mg/kg IV over 1-2 minutes.   IM for acute agitation   If a patient is out of control and a danger to themselves or others, administer 3 mg/kg intramuscularly (max 500 mg).   If you are giving IM ketamine it has to be in the concentrated 100 mg/ml vial.   Additional pearls   Pushing ketamine too quickly can cause laryngospasm.   Between .3 and 1 mg/kg is known as the recreational dose. You want to avoid this range because this is where ketamine starts to pick up its dissociative effects and can cause unpleasant and intense hallucinations. This is colloquially known as being in the “k-hole”.   References   Gao, M., Rejaei, D., & Liu, H. (2016). Ketamine use in current clinical practice. Acta pharmacologica Sinica, 37(7), 865–872. https://doi.org/10.1038/aps.2016.5   Lin, J., Figuerado, Y., Montgomery, A., Lee, J., Cannis, M., Norton, V. C., Calvo, R., & Sikand, H. (2021). Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. The American journal of emergency medicine, 44, 306–311. https://doi.org/10.1016/j.ajem.2020.04.013   Stirling, J., & McCoy, L. (2010). Quantifying the psychological effects of ketamine: from euphoria to the k-Hole. Substance use & misuse, 45(14), 2428–2443. https://doi.org/10.3109/10826081003793912   Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMS II

Episode 900: Ketamine Dosing

Contributor: Travis Barlock MD Educational Pearls:   Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes   Use of anticoagulants with INR > 1.7 or  PT >15    Warfarin will reliably increase the INR    Current use of Direct thrombin inhibitor or Factor Xa inhibitor     aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)     Intracranial or intraspinal surgery in the last 3 months    Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding    Current intracranial or subarachnoid hemorrhage    History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK    Recent (within 21 days) or active gastrointestinal bleed   Hypertension    BP >185 systolic or >110 diastolic   Administer labetalol before thrombolytics to lower blood pressure    Timing of symptoms    Onset > 4.5 hours contraindicates tPA    Platelet count < 100,000   BGL < 50    Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics    References 1. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532 2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211 Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

Episode 901: Underdosing in Status Epilepticus

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