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Monday, August 03, 2015

South Asians are more reluctant compared with other ethnicities to report pain and seek medication, according to a study published in the American Journal of Hospice and Palliative Medicine. (


Researchers at the University of Missouri School of Medicine conducted four focus groups and individual interviews with health care professionals who had experience providing care to seriously ill South Asian patients and their families. A total of 57 people participated, 23 of whom took part in the individual interviews and 35 of whom took part in one of the focus groups. They found that how physicians overseas treat pain and access to pain medications are different from the United States. The 1-10 pain scale used in U.S. EDs is not used in South Asia, for example, so patients may not be used to discussing pain in this context.


“Doctors in South Asia do not routinely ask patients about their pain like they do here,” said Nidhi Khosla, PhD, an assistant professor in health sciences at the MU School of Health Professions and the lead author of the study. “In South Asian culture, it is common for patients not to report their pain to avoid burdening others or being seen as weak.”


Dr. Khosla also said study participants said it is not uncommon for South Asian patients to be given low-dose pain medications like Tylenol after surgery, which is significantly different from the narcotics typically prescribed in the United States.


Read more:


Read more about pain management and medication in our archives.


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Friday, July 31, 2015

Emergency physicians can safely reduce x-rays in children with hurt ankles by as much as 23 percent and save emergency patients both money and time, according to results of a cost analysis published in Annals of Emergency Medicine. (


Researchers enrolled more than 2,000 children ages 3 to 16 with an acute ankle injury for three consecutive six-month phases at six EDs, and compared children with ankle injuries at EDs that did and did not use the Low Risk Ankle Rule (LRAR) assessment. Facilities using the LRAR saw 22.9 percent fewer ankle x-rays. Health care costs were $36.93 less compared with those that did not use the rule. Through reducing x-rays, researchers also did not find any significant differences in the frequency of missed clinically important fractures or in use of health care resources after a patient was discharged.


The authors concluded that “widespread implementation of the Low Risk Ankle Rule may lead to reduction of unnecessary radiographs for children and result in cost savings.


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Thursday, July 30, 2015
By Leon Gussow, MD

Severe calcium channel blocker (CCB) overdose is still a diagnosis that strikes fear into the hearts of many emergency physicians. These patients can deteriorate rapidly, and every clinician who has seen even one such case appreciates the importance of diagnosing the exposure quickly and treating it aggressively. Successful management isn’t difficult, however, as long as you keep these three pearls in mind when a patient presents to your emergency department after ingesting a CCB.


Calcium channel blockers are a so-called “triple threat: Calcium channel blockers can cause shock and cardiovascular collapse through a combination of three different pharmacologic effects. First, they impair cardiac contractility because, unlike skeletal muscle, the myocardial cells do not have sarcoplasmic reticulum that can store intracellular calcium. Contraction depends on calcium flux from outside the cells through specific channels. Calcium cannot enter myocardial cells efficiently when these are blocked, and the normal large calcium concentration gradient across the cell membrane cannot be maintained.


Secondly, CCBs cause vasodilation because vascular smooth muscle contraction also depends on calcium influx. This is why agents such as nifedipine and amlodipine are used to treat hypertension.


Lastly, calcium influx is crucial for the normal function of pacemaker cells in the sinoatrial node as well as transmission through the atrioventricular node and other conduction pathways. Overdose often presents with bradycardia, conduction blocks, and dysrhythmias.


The serum glucose level may be the most helpful single laboratory result in patients with CCB overdose: Calcium channel blocker poisoning affects the metabolism and utilization of glucose at two levels. First, release of insulin from pancreatic beta cells is mediated by calcium in a process impaired by high levels of CCBs. CCB overdose also induces insulin resistance in peripheral tissues. Both of these effects work to elevate glucose levels in CCB poisoning markedly.


In fact, the serum glucose level can provide diagnostic and prognostic information. A significantly elevated glucose level in a patient who presents with bradycardia and hypotension and is not diabetic strongly suggests CCB exposure. Generally, the higher the glucose level, the worse the prognosis. Some authors have suggested that the serum glucose level alone might serve as an indication to start high-dose insulin (HDI) therapy, although they have not cited a specific cutoff number. (Crit Care Med 2007;35[9]:2071.) A low glucose level, on the other hand, points more to beta-blocker toxicity.


High-dose insulin should be started early in significant CCB overdose: Under normal circumstances, the myocardium preferentially breaks down free fatty acids for energy. When the heart is stressed, however — as in CCB overdose — it switches to using carbohydrates for fuel. This requires insulin. But CCBs also interfere with insulin release from the pancreas. Cardiac function deteriorates without an efficient source of energy.


Unfortunately, medical literature concerning treatment of CCB overdose is less than robust. A recent systematic review of the literature concluded that “evidence for treatment of CCB poisoning derives from a highly biased and heterogeneous literature,” and “[b]ased upon the published literature, few valid inferences can be drawn about the relative merits of one intervention over another.” (Clin Toxicol [Phila] 2014;52[9]:926).


To paraphrase former Secretary of Defense Donald Rumsfeld, you go into the resuscitation room with the evidence you have, not the evidence you might want or wish to have at a later time. It’s still a matter of some debate among toxicologists, but a consensus is building that HDI is an effective therapy that should be started initially or at least relatively early in the course of treating significant CCB overdose. (Clin Toxicol [Phila] 2011;49[4]:277.)


Many clinicians in the past seemed uncomfortable ordering the 1 unit/kg bolus of insulin needed in many HDI protocols for fear of precipitating profound hypoglycemia. Experience has demonstrated that this is usually not a major problem. These patients almost always have elevated glucose levels on presentation, and CCB-induced insulin resistance gives added protection.


A number of years ago, our group published a case report that illustrated the margin of safety that exists when HDI is used to treat CCB overdose. A 100 kg 49-year-old man presented after ingesting 80 tablets of 100 mg verapamil SR. HDI was started, and he inadvertently received a bolus of not 1 U/kg, but — wait for it — 10 U/kg (1,000 units!) All of his hemodynamic parameters improved significantly after this bolus, and no episodes of hypoglycemia occurred.


Of course, glucose levels should be followed carefully in these patients, and supplemental dextrose administered. The local poison control center, which should be consulted about any patient treated with HDI, can supply up-to-date protocols.


Newer options are available for treating severely ill patients with CCB poisoning who do not respond to HDI. Some dramatic saves have been reported with use of lipid rescue therapy, but there is still not agreement about whether this should be used only as a last-ditch effort in a crashing patient or started at an earlier stage. Extracorporeal membrane oxygenation (ECMO), which I discussed in the April issue (, may be effective as a bridge to recovery when it is available. Right now, however, the key to treating these patients seems to be supplying good supportive care and initiating HDI therapy at an early stage when it is indicated.


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Wednesday, July 29, 2015

Florida Hospital Memorial Medical Center is looking to reduce hospital overuse through a program called Community Care, according to the Daytona Beach News-Journal (


The program started about a year ago in Daytona Beach and is now expanding to western Volusia County, where one ED frequent flier visited the emergency department 274 times from 2010 to 2012, racking up $1.4 million in charges, according to an analysis by the Florida Department of Health in Volusia County. The program is also set to reach Flagler County eventually. Hospital officials said they have already seen results by connecting their highest users to a team consisting of a nurse, dietitian, social worker, and health coach. They also calculated that the program has saved one frequent ED user $85,000 in health care expenses. This same patient has been to the emergency department 13 times and admitted twice since being admitted to the program in March 2014. Before that, she visited the emergency room 16 times and was admitted nine times.


Currently, about 120 people are participating. Qualified patients must be uninsured or on Medicaid, and the hospital selects them based on utilization data.


Often, most qualified patients need help scheduling appointments, understanding discharge instructions, and taking medication, according to a nurse with the program, and having workers help patients with these steps can eliminate the need for costly stays in the hospital.


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Tuesday, July 28, 2015

The distribution of the Glasgow Coma Scale (GCS) differed between young and old patients with traumatic brain injury (TBI) (22.1% and 9.8% had a GCS 3 and 8, respectively), despite a higher burden of anatomical injury in the elderly group, according to a study published in Emergency Medicine Journal. (


Researchers reviewed a retrospective database for patients presenting to a hospital in the United Kingdom between January 2009 and May 2014, from which they collected information for all patients with TBI. An abbreviated injury scale (AIS) was recorded for all patients, who were categorized into older and younger than 65 years old on presentation. Distribution of GCS, categorized into severe (GCS 3-8), moderate (GCS 9-12) and mild TBI (13-15) was compared among the age groups. Median GCS at each AIS level was also compared. Presenting GCS was higher in the elderly at each level of AIS. The difference was more apparent in the presence of more severe injury (AIS 5).


The authors suggest that triage tools using GCS may need to be modified and validated for use in elderly patients with TBI.


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