EM:RAP and AIR Infectious Disease (Jan 2020)
AIR: https://www.aliemu.com/courses/infectious-disease-2019/
EM:RAP for Asynchronous Learning! For credit, first, listen to the entire podcast. Your participation in the discussion board here is your attestation that you have listened and engaged with the content in a meaningful way.
EM:RAP: https://www.emrap.org/episode/emrap2020/january
When you have finished listening to the podcast, answer the following questions:
1. Please list three things you learned from this podcast that you were not aware of before.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
3. What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
4 comments
FOAM, literature changes and guidelines and risk management can affect practice decisions
“Clinical Bottom Line:
Despite the recommendations from the WHO, advocating for the use of Oseltamivir, health care providers should discuss the available evidence of benefit, harms, and costs of this medication. Until new evidence demonstrates conclusive proof of benefit over harm, oseltamivir should not be routinely recommended as treatment or prophylaxis in adults or children (Excluding immunocompromised patients).”
I find FOAM and definitiveness of author’s opinion or summary can be problematic vs discussing pros, cons, guidelines and that there are inherent limitations. While blogosphere is down on oseltamavir, reasonable people can have different yet reasoned opinions.
as my twitter note, this is recent data that one can use in patient shared decision making:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32982-4/fulltext
“Findings
Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20–1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74–1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30–1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00–5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group.
Interpretation
Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2–3 days sooner.”
EM MDs should also be aware of the environment we practice in and such statements (and successful claims) re:
https://www.gairgair.com/failure-to-diagnose-or-treat-influenza.html
IF A DOCTOR FAILED TO DIAGNOSE INFLUENZA OUR NYC MEDICAL MALPRACTICE LAWYERS CAN HELP
“When initiated promptly, treatment of influenza with anti-viral medications (Tamiflu, Relenza, etc.) can shorten the duration of symptoms, and reduce the severity and incidence of complications of the flu and flu associated death8. In otherwise healthy patients who are not at risk for developing complications of influenza, or who do not present with severe, progressive, or complicated illness, treatment with anti-viral therapy is most effective if administered within forty-eight (48) hours of symptom onset. In all other patients however, treatment with anti-viral therapy must be administered as soon as possible, regardless of time of symptom onset.
Failure to timely diagnose and treat influenza may constitute medical malpractice. If you or a family member developed serious complications from influenza that was not timely diagnosed, please contact our firm to discuss your case with a New York Medical Malpractice Lawyer.”
Also, one should at least be aware of CDC guidance
Summary of Influenza Antiviral Treatment Recommendations
Clinical trials and observational data show that early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of some complications from influenza (e.g., otitis media in young children, pneumonia, and respiratory failure).
Early treatment of hospitalized adult influenza patients with oseltamivir has been reported to reduce death in some observational studies.
In hospitalized children, early antiviral treatment with oseltamivir has been reported to shorten the duration of hospitalization in observational studies.
Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset in clinical trials and observational studies.
Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who:
is hospitalized;*
has severe, complicated, or progressive illness;* or
is at higher risk for influenza complications.
*Note: Oral oseltamivir is the recommended antiviral for patients with severe, complicated, or progressive illness who are not hospitalized, and for hospitalized influenza patients.
Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk for influenza complications, who is diagnosed with confirmed or suspected influenza, on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.
Summary – if I were providing the summary statement, I would suggest that as in all things, clinicians used shared decision making about use of antivirals and at least discuss some of the thinking about treat/not treat. This would be a different approach than one might conclude as a nihilist why test for flu if not going to treat?
thoughts?
jim
Totally agree with Jim.
.
I feel that we’re often WAY too dogmatic when it comes to issues where there is clinical equipoise. This is the same way with abx for strep throat, very low risk CP, Tamiflu for flu, and many many other issues in the ED.
.
Just tell the patient the limitations of the treatment, potential benefits and harms, and let them and their family decide together.
.
I understand that it’s time consuming, and some patients potentially may not be able to participate actively in these types of discussions. But more often people are open and appreciative of an informed decision making approach than we might think.
Three things I learned and how they will change my practice:
1. Unstable A fib – Loved hearing someone talk about when afib is more likely compensatory. We often see afib in our ER and immediately people are asking for rate control when often their blood pressure is well above a MAP of 65. I’m curious if we will move to a paradigm where we investigate further before immediately going for rate control. Additionally, I like the answer that the ideal heart rate in the elderly is probably 100-110 and not 7.45 was pretty shocking to me. I would imagine this would require several amps of 8.4% sodium bicarb. With all of the arguments about peripheral pressors/hypertonic therapy, it seems that bolusing multiple 8.4% solutions must show that maybe we can worry about this less. Further, if you mix isotonic bicarb, that’s only 3 amps in a full liter of fluid. That seems like a lot of volume in someone that you are worried about their ability to maintain respirations and avoid intubation which can cause rapid decompensation. Obviously in a sick patient, you are frequently taking VBGs and looking for a trend, but I think if you are reaching for multiple doses of bicarb, then you should already have Renal on the phone getting ready for dialysis because it doesn’t seem like a sustainable solution if someone is already acidotic in a salicylate overdose.
Too cutting edge for BMC (or for me):
– Norepi with esmolol is also a really novel idea I’ve never used before. In theory, it seems to make since, remove the chronotropy of norepi with beta blockade, however, I think in practice it seems like one of the cases where we are being too fancy for our own good. Phenylephrine is almost never used in the ER and cautioned against as a pressure despite the fact that it’s pure alpha agonism seems to be what the above combination is going for, and if it worked well, it would probably help with hypotensive afib and rate control due to its reflex bradycardia, however I’ve never heard of this used. I will say that I would like to explore more data on esmolol drips for rapid a fib because I know the cardiology community seems to favor this vs dilt which we are more comfortable with.
– Moral injury in ER boarding – while we’ve had tons of initiatives to deal with boarding at BMC, some with fairly significant success like having an overnight PA and an open C side overnight, our patient population as a whole will always work against ER boarding. It’s incredibly difficult trying to ensure a safe discharge plan in a patient population with no social supports, homeless, and with ongoing substance abuse. We are more fortunate than most hospitals to have services like Project Assert, but one hospital vs systemic city wide problems will always be a struggle. I anticipate we will always have patient’s in the hallways with little dignity to their medical care.
1. I learned a lot from the bariatric surgery segment; I had lumped all those patients together in my head previously due to lack of specific knowledge, so it was good to hear the specifics of each procedure and expected complications. I will still obviously be engaging my surgical colleagues with these patients, but the additional background information was very interesting. I also learned a few things from the ATLS segment as we don’t take ATLS at all during our training. A third thing that I learned was that patients with myxedema coma can present with isolated angioedema.
2. I will make use of the controlling rapid a-fib recommendations in the podcast. They did a great job of outlining normal/expected versus pathological RVR rates. I like the idea of norepi with esmolol as needed. There was one case I had in the MICU where a patient on 3 pressors went into A-fib with RVR and we added esmolol as a bridge and transitioned the epinephrine to phenylephrine. Very counterintuitive, but it works when the ventricular rates are getting way too high for good filling.
3. The case with the thoracotomy and resuscitative hysterotomy was bold and, fortunately, both mother and baby had good outcomes. There were a number of things in their favor (patient was being transferred and not 911 so more information was known, etc.). I think this is a one-in-a-career type case that most people will never experience and should not be routinely performed without coordinating with other services in the hospital as definitive care cannot be delivered in the ED.