Oxy morons. Avoid prescribing oxycodone

It has been interesting moon-lighting at another hospital to see how much oxycodone (common brands names: oxynorm and oxycontin) was being used professionally and recreationally.

I was out with a friend who told me he had been given 1 1/2 oxycontin tabs by an acquaintance a while ago and had been high as a kite for a couple of days.  Interestingly he said there was no “come down”.  Sounds like a very desirable drug of abuse.

In the ED everyone was prescribing oxycodone to everybody, from the ED reg to the ENT reg to the ortho house officer.

“… we are looking at a disaster in the making. We have been complacent about the warnings from the rest of the western world, with harms arising from pharmaceutical opioids overtaking those from heroin. This has reached epic proportions in the United States, with oxycodone particularly over-represented. Pharmaceutical opioids in the United States now kill more people than firearms or road traffic accidents, and more than the combined death rates from heroin and cocaine overdoses. This is shocking and shameful …” Dr Jeremy McMinn* 

Oxycodone is more addictive and more expensive than morphine.

Oxycodone is no safer in renal failure than morphine.

Most people with morphine “allergy” were just given too much  and developed nausea, vomiting, dysphoria or an itchy rash from the histamine release caused by morphine.  It may be worth try a test dose of IV morphine to see if they can tolerate it, check with a senior first.

Generally in ED for analgesia we use paracetamol/acetaminophen and a NSAID such as ibuprofen.  For severe pain we will use a fast acting IV or IN opioid such as fentanyl to control the pain.  Once the pain is controlled if ongoing strong pain relief is required we will move to oral morphine (or IV if unable to take oral).  Oral morphine is available in fast acting and slow release forms.

In our hospital we have made oxycodone only able to be prescribed by order of a consultant, and I’m trying to have oxcodone removed from our ED.

As an aside, at the other hospital, as always, there was a granny who had bounced back into hospital because she had been discharged from the ortho ward on oxycodone, prescribed a bulk forming laxative but no stimulant laxative, and hadn’t crapped for a week and felt rotten.

It’s a shame that the resident who discharged her wasn’t working that weekend.  It would have been a good educational experience for him/her to come down, give the enema and readmit the patient.

This is a problem with all opioids, not just oxycodone.  Always prescribe a stimulant laxative when prescribing more than a few doses of opioids eg something with sennosides in it.  By the way sennosides are Category A (considered safe) in pregnancy.  Shame the resident wasn’t on that weekend.

 

*Dr Jeremy McMinn is a consultant psychiatrist and addiction specialist at Capital & Coast DHB. He is also the Co-Chair of the National Association of Opioid Treatment Providers and the New Zealand Branch Chair of the Australasian Chapter of Addiction Medicine

References:

http://www.bpac.org.nz/BPJ/2014/June/upfront.aspx

http://nzf.org.nz/nzf_882.html?searchterm=sennoside

 

 

 

 

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Pull my finger. Dorsal dislocation of PIP

A young adult male sustained an open dislocation of the PIP for his middle finger while playing rugby.

Pull my finger

Hopefully he wasn’t doing a Hopoate.

195810-john-hopoate

The finger was neurovascularly intact.  The wound was not obviously contaminated.

The finger was anaesthetised using a ring block at the level of the web space and the wound was cleaned.

The clinician puts on gloves to give a better grip.  The proximal phalynx was held in the clinicians non-dominant hand with the clinician’s thumb on the palmer aspect where it can be used to stabilise the distal end of the proximal phalynx.

The clinician then grabs the rest of the finger in her/his dominant hand and pulls and hyperextends the middle phalynx.  The middle phalynx is then flexed reducing the dislocation.

The PIP joint was grossly unstable indicating disruption of the volar plate – the ligament joining the palmar aspect of the proximal phalynx to the palmar aspect of the middle phalynx.  The volar plate prevents hyperextension and dorsal dislocation of the joint.

Volar plate

Where there is a large avulsion fracture, say > 30% of the joint surface talk to hands/ortho about potential fixation of the fragment.

Generally the PIP is splinted with 30˚ of angulation with a zimmer splint (1cm wide malleable aluminium strip with foam on one side).  The middle phalynx does not need to be taped to the splint – so it can flex but not extend past 30˚ of flexion.  This is called a dorsal blocking splint.

dorsal blocking splint

If the joint is not unstable when relocated some advocate simply buddy strapping the finger to one of its neighbour.

The laceration was cleaned and sutured (being careful to avoid the flexor tendons).

Any finger dislocation should be reviewed by a hand therapist at about a week.

Open dislocations should be discussed with hands or ortho who may want to wash the joint.

Audio:

 

Diagrams from: http://www.aafp.org/afp/2006/0301/p810.html

Music: Flume remix of Tennis Court by Lorde

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Head injury – when to CT

Various attempts have been made to create guidelines as to who should be scanned after a head injury.

For someone who is not intoxicated, who has had a significant trauma and has a GCS < 13 it is usually a slam dunk: CT.

For those with a GCS of 13 or 14, or they are drunk things get more complicated.

Various guidelines have been made, mainly in attempt to reduce CT scanning in North America.  The Brits made their own version which increased scanning, without a significant patient benefit.  The specificity of these guidelines is terrible.

New Zealand has never been that over the top with our scanning, so we didn’t need to significantly reduce our scanning.  Rather we tried to provide some guidance for new docs when to scan and when not to.  A group including Prof Mike Ardagh used the research that the Brits and the North American’s based their guidelines on, but rather than aiming to identify all intracranial pathology (including cerebral contusions) they adjusted the clinical indications for scanning so that clinically significant abnormalities would be picked up, but some non-significant lesions would be missed.  For example vomiting in kids is ignored.

Even the NZ guidelines are a bit over the top saying all intoxicated people with a head injury and lowered GCS should be scanned as if they were not drunk.  This is fair enough if the patient has been in a car crash or fell down a big bank, but if there drank 10 litres of beer then fell over on to the grass and now have a GCS of 7 we will put them in the recovery position and keep a close eye on their GCS.  If their GCS is improving great hour by hour great.  If not scan ‘em.

Similarly if someone is drunk we don’t necessarily follow the old mantra of “GCS <8, intubate”.  Be very firm with your stimulus to assess GCS – do a good triceps pinch.  Again, we’ll put them in the recovery position and observe them closely.  If we intubated and scanned every drunk who might have had a head injury and a GSC less that 8 we would have no room in our ICUs.

Adult CT guidelines

Paed CT guideline

But take even this with a grain of salt.  Lots of kids will go to sleep after a bonk to the head, and we want to avoid irradiating those sensitive brains, so often unless the kid has had major trauma and is obviously munted we will observe them for a while before scanning them.  More often than not they will perk up after a wee power nap – a bit like an aging emergency physician.

Paeds GCS:

Paeds GCS

Neuro obs

Again, don’t take this as gospel.   I don’t expect our nurses to do a temperature every 15 minutes for a head injured patient with a lowered GCS.

The most important thing for someone with a lowered GCS is be in recovery position to reduce the chance of them vomiting and occluding their airway, and for regular checks to happen. 

I want continuous sats + GCS and pupils at the intervals stated above.

Audio:

Slides:

 

This post/podcast based on a talk by Dr Anna Waterfield and the following guidelines

TBI guideline – summary [2007]  NZ Guidelines produced by ACC, NZ

Winston Churchill audio from http://vimeo.com/simonappel/winston-churchill

Extradural image from: http://www.aic.cuhk.edu.hk/web8/extradural_haemorrhage.htm

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Old bones. Fractures can be hard to see. Get your eye in.

An 89-year-old tripped over her walker at the rest home. She had a history of a fractured R clavicle, but was not tender over her clavicle.

She had pain in her R groin and R shoulder.

Ctrl or Command + to enlarge, Ctrl or Command 0 (zero), to revert to normal size. 

Pelvis

and

R shoulder

inf pubic ramusinf pubic ramus with circle

SNOH

SNOH with circle

Undisplaced fractures of the right surgical neck of humerus and inferior pubic ramus.

These were both missed by the radiologist. We have the advantage of being able to poke the patient and see where they are tender.

And pain in the groin, rather than in the hip, after a fall in an elderly person is a fractured pubic ramus till proved otherwise.

Similarly pain in the shoulder in an elderly person is a fractured neck of humerus till proved otherwise.

This isn’t very exciting emergency medicine, the management is non-operative, but these fractures make a big difference to the analgesia requirements and the ability to self-care.

There is no way this patient could go back to her own room in a rest home to attempt to mobilise with her frame. This woman was admitted to hospital pending placement in hospital level care.

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Funky eyes. Alternating strabismus and impaired upwards gaze

An eye movement disorder not caused by a cranial nerve lesion
This is an interesting neuro case.
This is nothing you have to know for exams but it does help demonstrate some principles of eye exams, and helps us think about some important differentials such as botulism, which if we don’t think of in ED, no one else may think of.

This is a chap in his mid 50s who was referred in by his BP with 1 day of diplopia and altered sensation in his R hand and foot.

He got up to pee at 3 in the morning and noticed he had double vision and his hand and foot felt weird.  He had had mylagias the day before.

He had normal power of his lime, he had no right plantar response, he had mild past pointing bilaterally and mild right dysdiadocokinesis.  His gait was normal.

He had full range of movement of his left eye and impaired upward gaze on his R eye and he had an alternating squint.  If he fixed with his R eye his L eye deviated upwards and outwards. If he fixed with his L eye his R eye tuns down and out

His pupils were normal and the rest of his cranial nerves were normal.

Several docs had saw him and thought he had a lateral rectus palsy or a 3rd nerve palsy.

 

 

 

He has a conjugate gaze palsy or an internuclear ophthalmoplegia where the nerves that tell the eyes too look in the same direction are stuffed, he also has impaired upward gaze of his R eye.  Impaired upward gaze does not occur from one cranial nerve being taken out.  A third nerve palsy will have the eye turned down and out and a ptosis.  A fourth nerve (trochlear/superior oblique) palsy will will leave the patient unable to look down and out with the effected eye and a 6th nerve, or lateral rectus, palsy have consistent inability to abduct the affected eye.

With gaze palsies we need to be thinking about cranial nerve lesions, mono neuritis multiplex e.g. from diabetes, MS, snake and tic bites if you live some where like Australia, botulism esp in a floppy baby (bulbar palsy and descending paralysis, lack of fever, and clear senses and mental status (“clear sensorium”), Wernicke’s encephalopathy (usually with ataxia and confusion) and Miller Fisher syndrome (“upside down” Guillain–Barré) which usually has ataxia and areflexia.

The sudden onset, the fact that he was systemically well and the lack of other nerve involvement made me think this was likely to be a TIA/stroke effecting the midbrain

 

Music.  Tika Tonu by Hui-A

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