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Sunday, October 23, 2016
Dr. Walker interviews Alexis LaPietra, DO, about her Alternatives to Opiates (ALTO) program in his December 2016 and January 2017 columns, where these protocols appear. They are published here to include the references that went into creating them.

ALTO Clinical Applications

Renal Colic
1. Toradol 30 mg IV
2. Cardiac lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)
    a. Patient should be on a cardiac monitor.
3. Acetaminophen 975 mg PO
4. 1 L NS bolus

Musculoskeletal Pain (sprains, strains, or opiate naïve lower back pain)
1. Acetaminophen 975 mg PO
2. Motrin 600 mg PO or Toradol 30 mg IV/IM
3. Muscle relaxant (choose one of the following)
    a. Flexeril 5 mg PO (patients >65 years old or <70 kg or concerns for somnolence)
    b. Flexeril 10 mg PO (patients >70 kg)
    c. Valium 5 mg PO
4. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.
5. Gabapentin (neuropathic component of pain)
    a. 300 mg PO (patients >65 years old or <70 kg or concerns for somnolence/naïve to med)
    b. 600 mg PO (patients >70 kg or not naïve to med)
6. Trigger point injection with 1-2 mL of Marcaine 0.5% or  Lidocaine 1%

Acute on Chronic Radicular LBP (opiate tolerant)
1. Acetaminophen 975 mg PO
2. Motrin 600 mg PO or Toradol 30 mg IV/IM
3. Muscle relaxant (choose one of the following)
    a. Flexeril 5 mg PO (patients >65 years old or <70 kg or concerns for somnolence)
    b. Flexeril 10 mg PO (patients >70 kg)
    c. Valium 5 mg PO
4. Gabapentin (neuropathic component of pain)
    a. 300 mg PO
5. Dexamethasone 8 mg IV
6. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.
7. Trigger point injection with Marcaine 0.5% or lidocaine 1% 1-2 mL
8. Ketamine 0.3 mg/kg over 10 minutes 
    a. Ketamine 0.1 mg/kg/hour 

1. Reglan 10 mg PO/IV
2. 1 L 0.9% NS bolus
3. Motrin 600 mg PO or Toradol 30 mg IM/IV
4. Tylenol 1000 mg PO
5. Cervical or trapezius trigger point injection with Marcaine 0.5% or lidocaine 1%
If <50% pain relief then:
6. Magnesium 1 gm IV over 60 minutes
7. Valproic acid 500 mg/50 cc NS over 20 min
8. Dexamethasone 4-8 mg IV
If <50% pain relief then:
9. Haldol 5 mg IV

Extremity Fracture or Joint Dislocation
1. Ketamine intranasal 0.5 mg/kg (concentration 50 mg/mL)
    a. MAX dose 50 mg; MAX volume per nare 1 mL
2. Nitrous oxide titrate up to 70%
3. Tylenol 975 mg PO
4. Ultrasound-guided regional anesthesia (Print a picture with a new machine and scan into chart)
    a. Joint dislocation
        i. Lidocaine 0.5 % peri-neural infiltration (MAX 5 mg/kg)
    b. Extremity fracture
        i. Ropivacaine 0.5% peri-neural infiltration (MAX 3 mg/kg)

Used with permission. Copyright ©2015 St. Joseph’s Healthcare System. All Rights Reserved.

1. Balakrishnamoorthy R, Horgan I, Perez S, Steele MC, Keijzers GB. Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency department patients with low Back pain and RAdiculopathy (SEBRA)? A double-blind randomised controlled trial. Emerg Med J 2015;32(7):525.
2. Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med 2011;18(9):922.
3. Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008;336(7657):1359.
4. Cleveland Clinic Algorithm: http://bit.ly/MigraineOpioid​.
5. Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015;314(15):1572.
6. Fahmida Ghaderibarmi, Nader Tavakkoli, Mansoureh Togha. Intravenous valproate versus subcutaneous sumatriptan in acute migraine attack. Acta Medica Iranica 2015;53(10):633.
7. Ferrini R, Paice JA. How to initiate and monitor infusional lidocaine for severe and/or neuropathic pain. J Support Oncol 2004;2(1):90.
8. Galer BS, Gammaitoni AR, Oleka N, Jensen MP, Argoff CE. Use of the lidocaine patch 5% in reducing intensity of various pain qualities reported by patients with low-back pain. Curr Med Res Opin 2004;20(Suppl 2):S5.
9. Gelfand AA, Goadsby PJ. A neurologist’s guide to acute migraine therapy in the emergency room. The Neurohospitalist 2012;2(2):51.
10. Herres J, Chudnofsky CR, Manur R, Damiron K, Deitch K. The use of inhaled nitrous oxide for analgesia in adult ED patients: a pilot study. Am J Emerg Med. 2016;34(2):269.
11. Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, Eberhart LH, Poepping DM, Weibel S. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015 Jul 16;7.
12. Linde M, Mulleners WM, Chronicle EP, McCrory DC. Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodicmigraine in adults. Cochrane Database Syst Rev 2013 Jun 24;6.
13. Moore RA, Derry S, Wiffen PJ, Straube S, Aldington DJ. Overview review: Comparative efficacy of oral ibuprofen and paracetamol (acetaminophen) across acute and chronic pain conditions. Eur J Pain 2015;19(9):1213.
14. Cohen V, Motov S, Rockoff B, Smith A, Fromm C, Bosoy D, Hossain R, Likourezos A, Jellinek-Cohen SP, Marshall J. Development of an opioid reduction protocol in an emergency department. Am J Health Syst Pharm 2015;72(23):2080.
15. Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfanjani RM, Soleimanpour M. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol 2012;12:13.
16. Singh A, Alter HJ, Zaia B. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department? A meta-analysis and systematic review of the literature. Acad Emerg Med 2008;15(12):1223.
17. Vigneault L, Turgeon AF, Côté D, Lauzier F, Zarychanski R, Moore L, McIntyre LA, Nicole PC, Fergusson DA. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth 2011;58(1):22.

Wednesday, August 10, 2016

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Monday, August 8, 2016


Victims of life-threatening asthma attacks above all initially need supplemental oxygen, then nebulized or aerosolized albuterol. Dr. David Inwald, a UK pediatric intensivist, wrote in his BMJ article, "Oxygen Treatment for Acute Severe Asthma," that "the important point is that asthmatic patients are still dying during acute attacks, and the use of oxygen before, during, and after nebulised B2 agonist therapy in primary care and in the community is rational and could save lives." (2001;323[7304]:98.)

That prompted an innovation to fulfill his call.

During severe attacks, asthmatics are unable to negotiate an inhaler when it is used alone, and they are unable to make a seal around the spacer's mouthpiece when it is used with a spacer. Either way, albuterol inhalation is much reduced. And if the oxygen mask is already on the victim's face, it must be removed to (attempt to) provide the albuterol, depriving the victim of oxygen while trying. The pictured combination assembly solves this problem, allowing lay responder administration of oxygen and albuterol (as taught individually to lay responders by the American Red Cross, et al.) simultaneously without the need for any coordination or cooperation by the victim. This can make the difference while awaiting an EMS response.

A typical first aid oxygen unit's oxygen flow rate into its mask is 6.5 LPM continuous flow, approximately 108 ml/sec. A typical inspiratory time for severe asthma is one second at a typical respiratory rate of 30. In that one second with a good mask seal, inspiratory volumes above 108 ml would necessarily draw in albuterol contents from the spacer chamber after drawing in the oxygen. Inspiratory volume is proportional to body mass (5-8 ml/ kg for healthy breathing at rest), so a 100 kg patient will draw in the chamber contents faster than a 25 kg victim, though the smaller patient will still inhale all the contents with subsequent inhalations because the mask remains continuously on the face.

Either way, it is very expeditious and complete. The few victims who inhale less than 108 ml because of small size or extreme severity still at least get supplemental oxygen with each inhalation.

If, in spite of this more efficient treatment, the victim still goes into respiratory arrest, the spacer chamber/inhaler can be removed from the mask port, the one-way valve put back in, and oxygen-enriched rescue breathing can then be provided through the CPR mask. The ergonomics of this response is very simple and fast, especially if the spacer chamber and albuterol inhaler are pre-assembled and stocked with the first aid oxygen unit. If the victim does not, in fact, have asthma, the oxygen and albuterol are very unlikely to have an untoward effect for other conditions (and may still be of benefit).

The combination described — three devices and two drugs — falls under the regulatory oversight of the Office of Combination Products of the FDA, and it has yet to be determined if updated clearances by the manufacturers will be required for them to promote and advertise the described as an indication for use of their component as part of the combination. Respironics has clearance to market their Diamond spacer chamber with albuterol MDI plugged into the back end and their LiteTouch delivery mask plugged into the front end for use by those who cannot make and maintain a seal around the mouthpiece of the spacer when the mask is not used. The only effective difference between this and the proposed is oxygen flowing into the delivery mask.

Meanwhile, physicians are able to use "off-label" drugs and devices per their discretion and experience, as allowed by the FDA. Comments welcome.

Dr. Goldman is the inventor of Lif-O-Gen Automated First Aid Oxygen (http://lifogen.com) and the training and development coordinator for Lif-O-Gen Automated Blended Training (http://automatedoxygentraining.com), providing six free training certificates for each unit purchased from any distributor. He is also a former consultant to the First Aid Oxygen division of Allied Healthcare Products, Inc., a former director of emergency services at Malcolm Grow U.S. Air Force Medical Center at Andrews Air Force Base, and the first medical director of the American Safety & Health Institute. Watch a 45-second video on how to use the unit at http://bit.ly/1TT96x7.

Watch a short video of Dr. Goldman demonstrating how to attach the albuterol-spacer chamber to the Lif-O-Gen oxygen mask.


Friday, April 1, 2016

Emergency Department Treatment of Infectious Patients with Chicken Soup: Does It Improve Outcome?



Study objective:
The use of chicken soup in the symptomatic treatment of infectious disease is a well-known home remedy for the relief of symptoms and well-being advocated by mothers all over the world. We could find no published clinical trials, however, involving the use of chicken soup in the ED. Our goal was to see if the addition of chicken soup with standard treatment would improve patient's disposition and treatment outcome.

Methods: This non-controlled, non-blinded, non-randomized prospective study in a single center offered patients who presented to our ED with any complaints vaguely relating to an infectious disease treatment with chicken soup as part of their standard treatment. They were given a visual seven-point scale to report whether they were feeling better at disposition. Statistical analysis subsequently determined outcome improvement and patient satisfaction scores.

Results: Originally 1,989 patients were to be enrolled, but significant improvement in outcome was noted on early review of cases. The study was ended, and the use of chicken soup was added to standardized treatment protocols.

Conclusion: Mom was right. Chicken soup does improve all areas of measurement including patient improvement, satisfaction, and outcomes scores.

Decrease in Time to Defibrillation with the Use of a Remote Device



Introduction: Time to defibrillation/cardioversion (shock) in ventricular dysthymias has been shown in multiple studies to be the rate determinate step in outcomes for cardiac arrest victims. Decrease in time to shock has been shown by other studies to improve outcome in cardiac arrest victims. Our study was proposed to see if we could decrease this time interval by using a remote-controlled handheld device to initiate shock by the code leader.

Conclusion: Our study showed a decrease in time-to-shock by the use of a remote-controlled handheld device to initiate electrical shock in cardiac arrest patients in ventricular dysrhythmias, Times were not statistically significant because several outlier times messed up the results. These prolonged times to shock were looked at individually, and it appeared that the inability to find the remote contributed to the most significant time delays for those outliers. Future research should focus on how to make this process more efficient. We suggest incorporating the shock button into an app on cellular phones.

Using the Long Outward Exhalation (LOX) Maneuver for Conversion of SVT in the Emergency Department


We report a case of SVT that was successfully converted using a previously unreported technique for the cessation of SVT. An 18-year-old man presented to the ED with a fast heart rate. He denied any chest pain, lightheadedness, or shortness of breath. He also denied previous history of fast or irregular heart rate, family history, or recent ingestions of alcohol, sympathetic drugs, or tobacco.

The patient was alert, in no distress, and had a heart rate of 180 bpm and stable vital signs. His ECG showed a narrow complex regular tachycardia with a rate of 180. He was placed in a monitored room, a plain untoasted bagel was placed over his flips, and it was explained to him to use a long outward exhalation (LOX) for 15 seconds. This maneuver was tried twice without any success. After further discussion, we decided to place a piece of lox (salt-cured salmon) over the hole of the bagel. The patient was again instructed to take a long outward exhalation after placing the bagel and lox over his mouth. Conversion was almost immediate. Repeat ECG showed normal sinus rhythm with no changes. He was discharged home to follow-up with primary care in two to three days.

We hypothesized that exhaling through a plain bagel did not generate enough resistance to simulate a Valsalva maneuver, once but the lox applied to the outside of the bagel acted as a flutter valve, generating a 40 mm Hg pressure and 15 s strain, which has been shown to be needed for conversion. Further studies are needed to determine whether the LOX maneuver needs to be modified (i.e., toasting, cream cheese).

These April Fool's Day gems were brought to you by
Stuart Etengoff, DO, an emergency physician at Genesys Regional Medical Center in Grand Blanc, MI. He extends thanks to Stephen I. Rennard, MD, whose original research on chicken soup for URIs inspired him. (Chest 2000;118[4]:1150.)

In case you were wondering about the authors on these case reports, the first one was Dr. Oy Vey for the exclamation used by Jewish mothers everywhere when serving chicken soup to sick family members. C(hicken) N(oodle) Campbell stood for the soup. The authors of the second item were the last names often used by the Three Stooges when they played doctors on their show. The third case report used the words deli, kosher, and bagel as stand-ins for the doctors' names.

Friday, March 25, 2016