REBEL Cast Ep 51: The ABC’s of Palliative Care in the Emergency Department with Mari Siegel

Many of us have heard the saying that emergency medicine is the best 15 minutes of every other specialty. This, is in part, due to the wide breadth of disease and knowledge one must have to take care of patients.  In emergency medicine we typically focus on acute disease specific problems  and life sustaining treatments, but as the population gets older we are also having to deal with chronic conditions as well.  This was not an area that I was trained in residency, but certainly one that I am seeing more and more often.  There was a great review article published in the Journal of Emergency Medicine in January of 2018 titled, Palliative Care Symptom Management in the Emergency Department: The ABC’s of Symptom Management for the Emergency Physician. The lead author of this paper is Mari Siegel, MD, who I had the pleasure of interviewing for this episode.

REBEL Cast Episode 54 – Hyperoxia in the Critically Ill

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Lead Author

Mari Siegel, MD
Assistant Professor of Emergency Medicine
Temple University
Philadelphia, PA
Twitter: @marisiegel

Difference Between Palliative Care and Hospice Care

Palliative care is the prevention and relieving of suffering while supporting quality of life both for patients and families.  Hospice care falls under the umbrella of palliative care.  Both focus on symptom management, but hospice care is generally the appropriate service for patients who have ≤6 months to live or no longer want curative treatment, while palliative care is more appropriate earlier in a patients disease course.

The “Surprise” Question

Would you be surprised if this patient died in the next 2 years? If the answer is no, then this is a patient who should be considered for palliative care.

3 Types of Pain

  • Nociceptive Pain: This is from stretching or compression of organs
  • Neuropathic Pain: This is the hardest pain to treat and comes from nerve injury
  • Bone Pain: This is from bony mets or pathological fractures

Nociceptive Pain Treatment

Use a scale up  strategy starting with nonopioids and increasing in strength.  A great resource for this is the World Health Organization (WHO) Analgesic Ladder

 

Neuropathic Pain

This is the hardest pain to treat.  The best two options here are gabapentin (Neurontin) and pregabalin (Lyrica) (The paper does make other medication recommendations).  Mari stated that gabapentin is cheaper and covered by most insurance companies, but pregabalin is generally not.  Both medications are equally effective, but gabapentin has a longer up titration period of almost 9 days compared to 2 – 3 days for pregabalin.

  • Typical dosing for Neurontin starts at 100mg three times a day but this needs to be titrated up to 2400mg – 3600mg in 24hrs over several weeks
  • Neurontin can also cause fatigue, but if the medication is continued for 1 – 2 weeks, the fatigue goes away

Bony Pain

Mari likes to use NSAIDs as her first line medication.  The reason for this is that osteolytic activity in bony mets is most likely mediated by prostaglandins.  NSAIDs are prostaglandin inhibitors.  Dexamethasone 8 – 10mg also does a great job treating bony pain.  If the pain is not treated with the NSAIDs or steroids, the second line agents would be opiates.

Tramadol

We talked about this medication as well.  Tramadol PO 25 – 50mg q6h is the typical starting dose.  Tramadol is considered a second line agent in the WHO analgesic ladder.  The problem with tramadol is the metabolites can be toxic, and people metabolize it at different rates, so it’s not clear how much of an opioid you are giving any one patient.  Mari recommends using this medication with caution in patients with renal failure or liver failure and on SSRIs, SNRIs, MOIs, Triptans or any other medications that can lower seizure threshold or cause serotonin syndrome (At doses of <200mg/day you are not lowering seizure threshold).

Opioid Dosing

  • Depends if the patient is opioid naïve or opioid tolerant:
    • Opioid naïve: Start with low doses (i.e. Outpatient = PO Oxycodone 5mg q6hr and/or Oxycontin 10mg PO BID; Inpatient = IV morphine 2mg or IV hydromorphone 0.5mg)
    • Opioid tolerant: Patients on chronic narcotics can be handled by increasing their home doses by 50% or change them to a different opioid (when changing narcotics, use an opioid conversion chart and start at 50 – 75% of the equivalent dose)
  • IMPORTANT POINT brought up by Mari: Opioids should be ordered as standing orders and not as needed to keep ahead of the patients pain
  • Also always prescribe stool softeners to go along with the opioid medications (Colace + Senna)
  • Fear of Hastening Death? Not so fast…Starting patients on low doses of opioids will not hasten death, but even if this did occur, there is a law of double effect, which states anyone prescribing medications to manage symptoms of pain are legally protected
  • Converting between narcotics can be done using a narcotic conversion chart which can be found online, but Mari likes to use a FREE app called Opioids Dosage Conversion

Logo for the Opioids Dosage Conversion App

Example of Opioid Conversion Discussed on the Podcast

  • When converting from one drug to another calculate the morphine equivalent in milligrams and figure out what they are on over 24 hours:
    • So a patient is on 100mg PO long acting morphine q12hr (200mg over 24hrs) + 30mg of oxycodone in 24 hours = 245mg of oral morphine (30mg of oral morphine = 20mg of oral oxycodone –> so 30mg of oxycodone = 45mg of oral morphine)
  • When converting a patient to another opioid, dose the patient at 75% of the morphine equivalent dose to ensure you do not over-medicate the patient
    • Converting to hydromorphone for example: 245mg of oral morphine per day ≈ 60mg of hydromorphone –> 75% of this is 45mg of hydromorphone, which is what you would give the patient
  • So the patient would get 8mg of hydromorphone q8hr + their oxycodone for breakthrough pain

Nausea and Vomiting

Treatment is very complex, as there can be multiple causes for vomiting.  The most common causes of nausea and vomiting come for the chemoreceptor trigger zone (CTZ).  Mari stated that low dose haloperidol 2mg or chlorpromazine 1mg/kg IV are the best agents in these cases. Ondansetron would be a first line medication for chemotherapy-induced nausea and vomiting.

Dyspnea

This is a common complaint.  The reflexive 1stline treatment is not oxygen, it is opioids. Starting with a low dose of morphine IV 2mg is a good starting dose to relieve dyspnea.  Benzodiazepines are also useful if opioids fail to alleviate the patients pain (i.e. 0.5mg IV lorazepam).  These medications are synergistic, so starting at lower doses is recommended

Agitation

1stline treatment for this is haloperidol 1 – 2mg IV hourly with titration to effect.  Mari brought up a good point that benzodiazepines can cause paradoxical agitation, especially in the elderly.

Terminal Secretions (“The Death Rattle”)

  • 1st line treatment is with anticholinergics including atropine and glycopyrrolate.
  • Atropine 1% SL drops (ophthalmic drops) = 0.1mg IV –> Place 2 drops under the tongue to help dry up secretions
  • Glycopyrrolate 0.2mg IV q6hrs

How to Talk to Patients

  • Set the scene (quiet room with privacy)
  • Make sure you sit down so you are at eye level
  • Questions to help initiate conversation:
    • Ask the patient what do you know about your illness/condition?
    • Then ask, do you want me to tell you what I know? This really lets you know where the patient is at
    • What does it look like for you to have peace at the end of your life?
  • Comfort directed care is not giving up. Use positive terms like aggressively treat your pain

References:

  1. Siegel M and Bigelow S. Palliative Care Symptom Management in the Emergency Department: The ABC’s of Symptom Management for the Emergency Physician. JEM 2018. PMID: 28987298

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post REBEL Cast Ep 51: The ABC’s of Palliative Care in the Emergency Department with Mari Siegel appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

Is it Safe to Discharge Patients Home with Isolated Traumatic Subarachnoid Hemorrhage (itSAH)?

Background: I received a text message from one of my colleagues inquiring about discharging a patient home with isolated traumatic subarachnoid hemorrhage and to be honest I had heard about this practice, but was not completely aware of the literature around it.  Turns out from a PubMed search there was a meta-analysis published just this past year trying to answer this very question.  When I was a resident, which is not that long ago, the standard practice was for patients to be assessed by neurosurgery for management which usually involved ICU admission or a trip to the OR with ICU admission. Isolated traumatic subarachnoid hemorrhage (itSAH) is typically defined as the presence of a SAH in the absence of any other traumatic radiographic intracranial pathology.  So the question is, is it safe to discharge patients home with itSAH?

What They Did: This was a systematic review and meta-analysis to evaluate the outcomes of patients with itSAH with a presenting GCS of 13 – 15.

Outcomes:

  • Primary:
    • Need for neurosurgical intervention on presentation to hospital
    • Need for neurosurgical intervention at any point following initial trauma
  • Secondary:
    • Neurologic deterioration
    • Radiographic progression
    • All-cause mortality
    • Death due to neurologic insult

Inclusion:

  • Studies of any design, with the exception of review articles and small sample sizes (n <10)
  • Radiographically confirmed (CT or MRI) intracranial injury limited to itSAH
  • Initial GCS 13 – 15
  • Data on one of the following outcomes: Need for neurosurgical intervention on presentation, neurologic deterioration, radiographic progression, eventual need for neurosurgical intervention, all-cause mortality, or death due to neurological insult

Exclusion:

  • Studies prior to the year 2000 (2000 was the approximate time when high-resolution fifth-generation CT scanners became available)

Results:

  • 13 studies reporting on 15,372 patients included in the review
    • All but one study was retrospective
    • All studies performed at Level 1 trauma centers
    • Only 1 study outside the US

*Almost all patients for this outcome derived from one study with 197 out of 13,191 patients requiring neurosurgical intervention (Indications, details of neurosurgical intervention, or postoperative course not detailed)

**13 Patients with Neurological Deterioration (Key Bad Outcomes: 1 Bilateral SDH Requiring Evacuation & 1 ICH & Death from Herniation)

***Only one death could be determined to be from neurologic injury and this patient was on warfarin

Strengths:

  • Asks a clinically important question
  • First meta-analysis to examine the outcomes of patients with GCS 13 – 15 & itSAH
  • The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and Meta-Analysis of Observational Studies in Epidemiology guidelines
  • Data were verified for accuracy by a third author
  • Discrepancies were resolved by discussion and consensus and when necessary, with review of a fourth author

Limitations:

  • Funnel plots suggest a potential for publication bias when exploring need for neurosurgical intervention on presentation and eventual need for neurosurgical intervention as outcomes
  • The authors were not able to conduct a subgroup analysis to determine if deaths were due to intracranial or extracranial injuries
  • No randomized controlled trials in this meta-analysis meaning the quality of included studies was relatively low due to the retrospective nature of included trials
  • Elderly, children, and alcohol-dependent patients were not studied in this meta-analysis making it impossible to draw any conclusions in these patient populations
  • Only 3 studies in this meta-analysis published data regarding anticoagulant/antiplatelet use, which means we can’t really draw any conclusions in this patient population from this study
  • The vast majority of patients were from a single study that left out critical information.This likely biases the conclusions of this meta-analysis
  • Confidence intervals are relatively wide on neuro deterioration and death

Discussion:

  • An important point to note is that despite 0 – 26% (Cumulative incidence of 5.7%) of patients having progression of lesions on interval imaging, only 0.75% experienced neurological deterioration and 0.0017% eventually required neurosurgical intervention. Extremely low numbers!!!  As we are trying to cut down on health costs and ionizing radiation to patients, this seems to be an optimal group to forgo repeat imaging unless there are changes in neuro status or other unique factors.

Author Conclusion:“These patients experience very low rates of radiographic progression and neurologic deterioration and rarely require neurosurgical intervention or die due to neurological injury.”

Clinical Take Home Point: Based on the methodologically limited data available, it does not appear that patients with itSAH are at a significant risk of requiring neurosurgical intervention, decompensation, or death.  However the poor quality of the included studies prevents us from making a strong recommendation.  It is instead, advisable to discuss this literature with your neurosurgeons and create a protocol based on regional best practices. No conclusions can be drawn about patients on anticoagulation/antiplatelet agents, the elderly, children, or patients with alcohol and drugs in their system based on this meta-analysis.

References:

  1. Nassiri F et al. The Clinical Significance of Isolated Traumatic Subarachnoid Hemorrhage in Mild Traumatic Brain Injury: A Meta-Analysis. J Trauma Acute Care Surg 2017. PMID: 289697013

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post Is it Safe to Discharge Patients Home with Isolated Traumatic Subarachnoid Hemorrhage (itSAH)? appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK)

Background: Alteplase is a tissue plasminogen activator that is approved for use prior to thrombectomy in ischemic strokes with the goal of reperfusion to ischemic areas of the brain. Tenecteplase is a recombinant enzyme derived from alteplase that is more specific to fibrin and more resistant to inactivation by alteplase inhibitors. Tenecteplase is less expensive, can be administered at a faster rate than alteplase and has a longer half-life allowing for bolus dosing. Prior studies have shown similar to better outcomes with use of tenecteplase versus alteplase in patients with ischemic stroke.

Campbell BCV et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. NEJM; 378(17): 1573-1582. PMID: 29694815

Clinical Question: In patients with ischemic stroke who undergo thrombectomy is tenecteplase non-inferior to alteplase in establishing reperfusion?

Population:

  • Adult patients
  • Thrombolysis administered within 4.5 hours of onset of ischemic stoke
  • Cerebral vascular occlusion on CT of internal carotid artery, first or second segment of middle cerebral artery or basilar artery
  • Thrombectomy within 6 hours of stroke onset
  • CT-perfusion mismatch for anterior circulation strokes (removed after 80 patients enrolled)

Intervention:  tenecteplase (0.25mg/kg; max dose 25mg) prior to thrombectomy

Control: alteplase (0.9mg/kg; max dose 90mg) prior to thrombectomy

Outcomes:

  • Primary outcome:
    • Restoration of blood flow to greater than 50% of the involved territory or no retrievable thrombus during thrombectomy
      • Used modified Treatment in Cerebral Ischemia classification (0 = no flow, 3 = normal flow)
    • If no thrombectomy, perfusion of at least 50% of involved territory on CT perfusion 1-2 hours after thrombolysis
  • Secondary outcome:
    • Modified Rankin Scale (mRS) at 90 days
    • Early neurologic improvement (reduction of NIHSS by at least 8 or a score of 0-1 at 72 hours)
    • Death – any cause
    • Symptomatic intracerebral hemorrhage
    • Parenchymal hematoma

Design: Investigator-initiated, multi-center, prospective, randomized, open-label, blinded-outcome non-inferiority trial

Excluded: Severe preexisting disability (modified Rankin score of greater than 3)

Primary Results:

  • 204 patients enrolled at 12 Australian and 1 New Zealand center between March 2015-October 2016
    • 101 assigned to tenecteplase group
    • 101 assigned to alteplase group
    • 2 excluded (1 withdrew consent, 1 eligibility error)
  • 6 patients had primary outcome measured by CT-perfusion only
  • Both groups had similar baseline characteristics
    • Age (~70yo)
    • Sex (~50% male)
    • Middle cerebral artery occlusion most common (74 patients)
    • Time to hospital presentation after symptom onset (~65 min)
    • Time to thrombolytics (~130 min)
    • Time to thrombectomy after thrombolytics (~55 min)
    • Hospital transfer post-thrombolytics (~25% of patients)

Critical Results:

  • Substantial (> 50% restoration of blood flow) reperfusion (primary outcome)
    • 22 in tenecteplase (22%) vs 10 in alteplase group (10%)
    • Absolute difference: 12% (CI 2 – 21, p < 0.002)
    • Incidence ratio: 2.2 (CI 1.1 – 4.4, p < 0.03)
    • Odds ratio: 2.6 (CI 1.1 – 5.9, p < 0.02)
    • NNT = 8

Secondary Results:

Strengths:

  • Asks an important question that could potentially lead to a medication shift
  • Included patients requiring transfer (increasing applicability)
  • Adequate randomization
  • Multicenter study
  • Follow up was excellent
  • Outcome assessors were blinded to treatment allocation

Limitations:

  • Only included patients undergoing thrombectomy (13% of ischemic stroke patients)
  • Median time from stroke to hospital arrival was longer in the alteplase group 72min vs 60min.  This difference is of unclear importance
  • Small sample size – only 204 patients enrolled over 19 months across 13 hospitals
  • Trial was unblinded to clinicians
  • Lack of transparency regarding patient enrollment (no flow chart)
  • High mortality compared to symptom improvement

Author’s Conclusions: “Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset.”

Our Conclusions: Tenecteplase results in improved perfusion after thrombectomy compared to alteplase but only in patients that undergo endovascular intervention. Additionally, the rates of reperfusion prior to thrombectomy were low in both groups (22% in telecteplase vs 10% in alteplase group). There are no differences in clinically significant outcomes.

Potential Impact to Current Practice: This study only applies to a small subset of patients with strokes (ischemic, large-vessel, undergoing thrombectomy) so there is unlikely to be a difference in large population outcomes. However, hospital stroke outcomes are of increasing importance so if tenecteplase costs less and requires less time to administer, this data may lead to a shift in management.

Bottom Line: Neither alteplase or tenecteplase are very effective in significant vessel reperfusion. Though alteplase is the drug of choice currently in ischemic stroke, tenecteplase may provide more cost-effective and time-efficient option.

Guest Post By:

Leah McDonald, MD
PGY3 Resident
NYU/Bellevue EM Residency Program

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References:

  1. Parsons M, Spratt N, Bivard A, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med 2012; 366: 1099-107.
  2. Campbell BC, Mitchell PJ, Churilow L, et al. Tenecteplase versys alteplase before endovascular thrombectomy (EXTEND-IA TNK): A multicenter, randomized, controlled study. Int J Stroke 2018;13:328-34.

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

The post Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.