Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Can You Spot Hyper-K on ECG?

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ECG can’t be used to rule out hyperkalemia. It may be present and electrocardiographically silent. But if you see the changes, ECG can be used to rule it in. Sensitivity was 19%; specificity 97%.

Why does this matter?
Corey Slovis teaches hyper-K = ECG. And this is true. There are ECG changes which portend bad things in hyperkalemic patients. But is the ECG a good screening tool to detect hyperkalemia?

Hyper-K still = ECG
This was a retrospective review of emergency physician evaluation of ECGs in patients with ESRD on hemodialysis. In this cohort with poor access to dialysis, prevalence of hyperkalemia was 60%, with half of those over 6.5meq/L. They had a prior dataset with paired ECGs and electrolytes. Bundle branch blocks, LVH, poor tracings, and paced ECGs were excluded. They selected 66 ECGs, 60% of which were in patients with hyperkalemia but spanned a range of potassium values, from normal to very severe. These were assessed by eight ED attending physicians at this single center, with a range of clinical experience from 1- 25 years. Overall, sensitivity was poor for detecting hyperkalemia on ECG, 19%; specificity was 97%. For the subgroup with K > 6.5, sensitivity was 29%, specificity 95%. The most common way kyperkalemia was detected was, “T-wave amplitude in 97.5%…, QRS length in 14%, prolonged PR duration in 6%, and P-wave changes in 15%.” My take away is the ECG is a poor screening test, but if you see the tell tale changes, you’re probably right. In other words, you can’t rule out hyperkalemia with ECG, but you can rule it in. Like Corey Slovis says, hyper-K still = ECG.

Can physicians detect hyperkalemia based on the electrocardiogram? Am J Emerg Med. 2019 Apr 22. pii: S0735-6757(19)30260-8. doi: 10.1016/j.ajem.2019.04.036. [Epub ahead of print]

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For more on HyperK, see this emDocs Post.

#2: Tramadol Isn’t Addictive, Right?

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Use of tramadol post-op was associated with an increased risk of prolonged use compared with other short acting opiates.

Why does this matter?
Tramadol is a, “synthetic weak μ-opioid receptor agonist,” and is, “phenotypically distinct from conventional short acting opioids.” It also has some SNRI and SSRI effects. As such, tramadol has been seen as an opioid alternative and as possibly less likely to have abuse potential. It is schedule IV in the US, as opposed to morphine or oxycodone, which are schedule II. Is it less addictive?

Trama-do or Trama-don’t?
Using Medicare Advantage claims data, a cohort of >350,000 opioid naive patients undergoing elective surgery were more likely to have prolonged opiate use when tramadol was prescribed compared to three other short acting opiates. They statistically adjusted for known confounders, such as total morphine milligram equivalents (MME) at discharge and others. Risk of any additional opiate prescription fill 90-180 days post-op was 6% higher with tramadol vs other short acting opiates; risk of persistent use ≥90 days increased 47%; chronic use increased 41%, all statistically significant. It is a myth that tramadol is safer or less addictive than other short acting opiates. This suggests it may be even more risky for prolonged use.

Chronic use of tramadol after acute pain episode: cohort study. BMJ. 2019 May 14;365:l1849. doi: 10.1136/bmj.l1849.

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#3: ACEP Unscheduled Sedation Guidelines

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This guideline for unscheduled sedation is based on good evidence and authoritatively states some key aspects of emergency sedation that apply to our patients and fit the needs of our setting.

Why does this matter?
Unscheduled sedation is categorically different than elective scheduled sedation and needs a separate guideline. We manage acute illness leading to urgent, time-sensitive sedation. Fasting may not be an option. Patients may or may not be completely stable or have definitive diagnosis yet. Goals are often different. Regulatory standards for elective sedation don’t apply.

Don’t fall asleep reading about sedation
This was a long paper, with a ton of information. Here are the highlights:

  • Patient and family centered: “Delaying procedural sedation for reasons not supported by evidence [such as NPO status] may result in extended periods of unremitting pain and anxiety with a negligible decrease in risk and must be avoided.”

  • Sedation is a continuum, except for dissociative sedation – which is especially useful when not NPO, in children, and those with comorbidities.

  • Sedation committees should be multidisciplinary.

  • They state that to monitor sedation, it is better to use airway patency and effectiveness of ventilation, using SpO2 and EtCO2, rather than the older model of assessing depth of sedation by verbal or tactile responsiveness.

  • The depth of sedation is more important, rather than a focus on excluding certain drugs (i.e. propofol or ketamine) as “restricted” for use by only certain specialists. Any opiate or sedative is capable of producing general anesthesia in high enough doses, so the decision to exclude certain drugs is arbitrary.

  • If a clinician has the training and skill set, this is what should determine sedation privileges, not speciality.

  • Recording of “adverse events” should only consider those requiring an intervention. If a patient has 30 seconds of apnea but no change in any physiologic parameter and requires no intervention, is this an adverse event? The authors would say no.

  • Recognize that the evidence base and clinical practice has far outstripped the FDA, and almost all of the sedation medications are off-label per the FDA for the indications for which we use them.

  • They advocate for a two person team for sedation: the sedation provider and sedation monitor, who may be a trained nurse or RT. EM gives us all the requisite skill to be a sedation provider.

  • They do not think a separate person is needed to provide sedation and perform the procedure, as long as there is a sedation monitor. This has been done safely for years, and the evidence does not support an increase in safety having two separate people – one to sedate, one to do the procedure.

  • They strongly advocate for nurse administration of sedative drugs. State licensure barriers should be lifted.

  • Competency in providing sedation is generally met by providers who regularly perform a number of sedations per year.

  • A pre-sedation assessment should be performed to determine target depth, agent, duration, and risk. This includes a brief H&P, Rx, allergies, prior sedation problems, airway assessment – obese, cancer, etc. High risk patients should go to the OR. Consent should be obtained. ASA I and II patients are very low risk.

  • NPO – “Currently, there is no evidence that non-compliance with elective fasting guidelines increases the risk of aspiration or other adverse events.” There are only 9 cases of death following aspiration during sedation since 1984, 8 of which were in patients undergoing upper GI endoscopy.

  • Drug regimen is tailored to the patient and situation. Combinations are acceptable.

  • Oxygen, suction, airway, ventilation, IV, and monitoring equipment must be available.

  • A pre-procedure time-out should verify identifiers, procedure, agents, doses, allergies, surgical site and side (R or L).

  • Most sedations should be monitored with pulse oximeter, cardiac monitor, and capnography.

  • High-flow oxygen should be avoided if not using capnography.

  • There is no need to assess toleration of oral intake during recovery prior to discharge.

  • Departments should maintain QI. TROOPS is a way to track sedation outcomes.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019 May;73(5):e51-e65. doi: 10.1016/j.annemergmed.2019.02.022.

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