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Jun 23rd, 12

ACEP Issues Clinical Policy on Opioid Prescribing for Patients Presenting to the Emergency Department

Deaths due to prescription opioids are a significant problem, accounting for nearly 15,000 fatalities in 2008 (a more than threefold increase compared to 10 years previously).  In fact, deaths due to drug overdoses are second only to motor vehicle crashes as a cause of injury-related deaths.  The American College of Emergency Physicians (ACEP) has recognized that this is an issue of significant public health concern and has issued a new policy addressing issues with prescribing opioids to patients presenting to the emergency department (ED).  Among the highlights:

  • The use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shopping.
  • Emergency physicians should determine whether nonopioid analgesics (i.e., acetaminophen or NSAIDs) may be adequate for initial pain management.
  • Given the risks associated with opioid use, misuse, and abuse, opioids should be reserved for more severe pain or pain refractory to other analgesics rather than routinely prescribed.
  • If opioids are indicated, the prescription should be for the lowest practical dose for a limited duration (e.g., <1 week), and the prescriber should consider the patient’s risk for opioid misuse, abuse, or diversion.
  • Physicians should avoid routinely prescribing outpatient opioids for a patient with an acute exacerbation of chronic noncancer pain seen in the ED.
  • ED physicians should attempt to honor existing patient-physician pain contracts/treatment agreements and consider past prescription patterns from information sources such as prescription drug monitoring programs.

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Jun 18th, 12

Hydroxocobalamin Superior to Sodium Thiosulfate for Treating Severe Cyanide Toxicity

Dr. Tanen’s new article on treatment of acute cyanide toxicity has just been published in Annals of Emergency Medicine.  Dr. Tanen and his co-authors induced severe cyanide toxicity a swine model and then administered one of three treatments: hydroxocobalamin (the active ingredient in Cyanokit), sodium thiosulfate (one of the primary components classically used for treatment of cyanide toxicity), or hydroxocobalamin + sodium thiosulfate.  There was 100% mortality in the sodium thiosulfate group versus 8% mortality in the hydroxocobalamin group and 17% in the hydroxocobalamin + sodium thiosulfate group.

This adds to the growing body of literature suggesting that hydroxocobalamin should replace the original cyanide antidote kit as the standard treatment for severe cyanide toxicity.

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Jun 15th, 12

Researchers Identify Risk Factors for Death from MRSA Bacteremia

A new study by Dr. Mina Pastagia et al. has identified risk factors for death from bacteremia due to MRSA.  In a retrospective study of 699 cases of MRSA bacteremia in 603 patients, researchers noted that advanced age, residence in a nursing home, severe bacteremia, and organ impairment were independently associated with increased risk of death.  Consultation with an infectious disease specialist was associated with a significantly decreased risk of mortality.

Overall mortality was 31.5%.  More than 40% of the patients had had surgery within the previous 3 months, and in 43% of cases a central venous catheter was found to be the source of infection.

According to the lead author, “The consequences of MRSA bacteremia are clear — many patients will die or experience a decline from their baseline clinical condition.  The adjusted risk difference enables clinicians to use a targeted approach, directed toward patients with the highest risk of death… These patients should be treated carefully and should possibly receive a consult from an infectious diseases specialist.  What remains unclear is whether patients at increased risk for death should be treated with antimicrobial drugs other than vancomycin.”

These findings can help clinicians to estimate the risk that a patient with MRSA bacteremia will die and to determine the need for infectious disease consultation, thereby potentially improving the chances that the patient will survive.

 

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