Pain Control: Toradol

Working in a surgical specialty, I have had to learn how to manage pain successfully.... and I must admit with some patients, I'm still learning. Pain is subjective so there is no magic recipe that works for every patient... you will have patients that 1) have intolerable side effects or allergies to your normal post op prescriptions, 2) have a history of narcotics abuse, 3) are drug seekers, 4) are people in true pain, and 5) are everything in between. It is good to have an idea of different pharmacological options to treat pain. Over the next few entries I will go over some of the main pain medications we use and some random ones as well.

TORADOL (ketoraolac tromethamine)

Key points:

• only parenteral NSAID approved for use in pain control in US
• Analgesic effect is more potent than anti-inflammatory
• Single dose administration = 30mg IV or 60mg IM (in healthy adult)
• Multiple doses = 30mg IV/IM q6hrs (max 120mg/day)
• PO is available, but used only as a continuation of IV/IM therapy - comes in 10mg tabs

Why might you use toradol?

• if constipation is an issue with your patient
• if you are worried about sedation/respiratory depression 
• patients with narcotic dependency
• if your patient gets nausea with narcotics

Cautions:

• do not use for > 72 hrs of pain control - some say 5 days is the max
• can prolong bleeding time (secondary to platelet inhibition) in post op patients - use caution 
• although injections bypass the GI system, patients can still get GI irritation
• monitor for renal side effects

Source: Handbook of Neurosurgery Greenberg, 6th Ed

Preoperative Patients on Coumadin

If you work in surgery or with the elderly - anticoagulation is an every day part of life. INRs, PTs, PTTs, etc... it is important to know what measures what and what reversal agents (if any) are available. Let's talk about Coumadin today.

Scenario: 79 yo patient is coming in for a surgical procedure, but he is on Coumadin. You did your due diligence and had them stop it about 5 days pre-op, but their INR is still 1.6 on preoperative blood work. What are your next steps?

Generally if you are going to bring someone to the OR you'd like their INR to be less than 1.5. If it is higher, you would consider a reversal agent.

Your 1st option for reversal is Vit K. 

• PO is most predictable and is preferred to IV if rapid reversal is not needed. PO Vit K lowers INR in about 24-48 hours. 
• IV works in approximately 12-24 hrs, but you run a greater risk of anaphylaxis and it must be administered over a longer period of time (approx 20 minutes). 

Your 2nd option for reversal is Fresh Frozen Plasma (FFP).

• FFP is more expensive than Vit K, but works within 12 hrs. FFP replaces clotting factors.

So, even though you did your due diligence, why was the INR still high? There are several reasons that can delay the drop of a patient's INR:

1. Age - Elderly pts
2. Malignancy (active)
3. Liver disease
4. CHF, unstable
5. Meds that keep Coumadin around in the blood (check their med list)

Sources:

Ansell, J, Hirsh, J, Poller, L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:204S. 

Normalization of INR After Stopping Coumadin: http://www.fpnotebook.com/mobile/HemeOnc/Surgery/PrprtvAntcgltn.htm

Oliguria

As always... back to the basics:

What is oliguria?
Low urine output (UOP)

What is "normal" adult UOP?
About 30cc/hr

How might you write a post op floor order for this?
"call house officer if 2 hour UOP is < 60cc"

What are the possible causes?
Think pre renal/renal/post renal causes

What is the most common cause?
Pre renal!

Causes of Renal Failure

Causes of Renal Failure broken down by pre-renal, renal, and post-renal.

Source: Clinical Survival Guide for PA Students by G.Broughton, MD, PhD

What if PAs Couldn't Suture Anymore?

This a repost from a call sent out by the AAPA based on a resolution brought to the AMA's House of Delegates. Read it and take part in your future scope of practice as a PA.

Join AAPA in responding to negative AMA resolution

While workforce experts are predicting a shortage of providers with the implementation of the Affordable Care Act, the American Medical Association Board of Trustess is proposing a resolution for its House of Delegates that could severely restrict PAs' ability to provide care to patients. PAs should be very concerned about the resolution, which will be considered by the AMA HOD when it convenes on Saturday, June 15. The recommendations are very restrictive and display a misunderstanding of the way PAs and doctors provide care as part of a team. Among other restrictions, the resolution expands the definition of surgery to include repair and removal of human tissue and, although parts of the resolution are somewhat unclear, states that surgery as defined in the resolution is to be performed ONLY BY PHYSICIANS. If adopted as presented, the resolution will call into question procedures like suturing, punch biopsies and vein harvesting, which PAs perform on a daily basis across many medical specialties. The resolution also proposes that only physicians should perform invasive procedures that utilize radiologic imaging. You can read Report 16 of the AMA Board of Trustees in full here.

AAPA is spreading the word about the negative impact this resolution would have on patient care and PA practice, but we need your help. Please review the list of AMA delegates in your state or specialty, and if you have a connection, please let that physician know the true damage that this resolution could create. Also, talk with and encourage physicians in your practice to speak with other physician leaders about the resolution. AAPA's suggestion is that the resolution should be defeated, or modified to specifically state that it does not apply to PAs practicing within the parameters of state law.

For more information on the AMA resolution please contact Ann Davis, PA-C, MS, Senior Director of Constituent Organization Outreach and Advocacy, at ann@aapa.org.

Atrial Fibrillation

AFib, The Basics

Characteristics

1. irregularly iregular
2. irregular RR intervals
3. not a P wave in front of every QRS
4. atrial rate = 400-600bpm, ventricular rate = 80-160bpm

Etiologies = PIRATES

P = pulmonary (COPD, PE)/pheo/pericarditis

I = ischemic heart dz +/- HTN

R = rheumatic heart dz

A= anemia/atrial myxoma

T = throtoxicosis

E = ethanol ("holiday heart)/cocaine

S = sepsis (post-operative)

Signs/Symptoms

1. fatigue (most common)
2. tachypnea
3. palpitations
4. lightheaded

Work Up

(Test yourself... why would you order each of these? what are you looking for?) - answers below

1. EKG
2. ECHO
3. TSH (?)
4. Baseline coags

1. EKG = narrow complex QRS (<120msec), variable RR, irregular or absent P waves
2. ECHO = maybe thrombi, maybe dilated L atrium
3. TSH (?) = hyperthyroidism can cause AF
4. Baseline coags = getting baseline prior to starting anticoagulation

Of note: if you are looking for THROMBI..."normal" ECHOs (transthoracic) has low sensitivity - transesophageal ECHOs allow for better visualization of L atrial appendage (location where most thrombi form) 

source: First Aid for the Wards by Le, Bhushan, Skapik

pic source: http://www.saintvincenthealth.com/Services/Heart/Heart-Resource-Library/Atrial-Fibrillation/default.aspx

Diabetes Insipidus, Part 2

Diagnosing DI

Polyuria = urine vol > 3L in 24 hrs - there are many causes of polyuria and it is important to figure out if the cause is DI or something else prior to establishing treatment

Urine osmolality (osm) of > 300 mOsmol/kg + high serum glucose --> think diabetes mellitus
Urine osmolality (osm) of > 300 mOsmol/kg + high serum urea --> think renal dz
Urine osmolality (osm) of < 200 mOsmol/kg + polyuria --> think DI

So you have a patient that has urine ohm < 200 + polyuria and you are thinking DI... how do you differentiate between central DI and nephrogenic DI?

Answer: water deprivation test

Findings:
Central DI
urine osm < plasma osm after dehydration
after ADH injections urine osm increases by >50%

Psychogenic DI

urine osm > plasma osm after dehydration

after ADH injections urine osm increases minimally

Nephrogenic DI

urine osm < plasma osm after dehydration

after ADH injections urine osm increases by <50%

Source: 
Makaryus/Mcfarlane. DI: diagnosis and treatement of a complex disease Cleveland Clinic Journal of Medicine Jan 2006 Vol 73:1
pic source: medicaltextboks.blogspot.com

Calculating and Interpreting ABI

http://www.strokescaninc.com/abi.htm

First things first...
What does ABI stand for? 

Ankle-Brachial Index

What arteries are you examining?

Brachial and Dorsalis pedis

How do calculate ABI?

R ABI = highest avg ankle pressure (R dorsalis pedis)/ highest avg arm pressure (either arm)
L ABI = highest avg ankle pressure (L dorsalis pedis)/ highest avg arm pressure (either arm)

http://www.mayoclinic.com/health/medical/IM04412

How do you interpret the #s?

ABI                     Interpretation

>0.90                   Normal LE flow

<0.89 - >0.60      Mild PAD

<0.59 - >0.40      Moderate PAD

<0.39                   Severe PAD

See more about the technique of gathering ABI data in an older ABI post of mine...



Source: Bates Pocket Guide of Physical Examination 6th Ed

Differentiating the Shakes

Essential Tremor v. Parkinson's Disease, Simplified

Of course this topic could be covered in much more depth than shall be covered here... but this is designed to cover the big picture and help you study for the PANCE.

ET
Characteristic: postural and/or intention tremor, meaning when the patient attempts to do something with their arms, the tremor appears or gets worse... these patients have difficulty with eating and drinking. 
Treatment: propranolol and primadone
Other notes: ETOH usually makes tremor BETTER, 50% of pts have a + family hx, tremor can affect voice (remember to ask the pt to say "EEEEEEEEEEE" - you often hear shaking)



PD
Characteristic: resting tremor
Treatment: sinamet, levodopa-carbidopa
Other notes: other PD sx = bradykinesia (slow movements), cog wheeling with passive movements




Source: Hardcore Pathology, by Wahl

Perinatal Infections

Perinatal Infections...

TORCH

Toxoplasmosis
Other (syphillis) - I always hate when "other" is one!
Rubella
Cytomegalovirus
Herpes










Source: Hardcore Pathology by Wahl

PANCE Study Material: Male Reproductive Jargon

PANCE Study Material: Male Reproductive Jargon

HypOspadias = abnormal urethral opening underneath (remember hypO means "below")
Epispadias = abnormal urethral opening above (remember epi means "above")

*Phimosis = foreskin is too tight to retract over glans
*Paraphimosis = foreskin is too tight to return back to its usual position

*Usually congenital, but can be caused by trauma or infectious scarring




Source: Hardcore Pathology by Wahl

Malignancy Buzz Words

What are the sign/sx and the associated diagnosis with the following buzz words?

(Answers below)

1. Virchow's node

2. Pancoast's

3. Lambert-Eaton
(NO PICTURE)

 
4. Trousseau's

5. Peau d'orange

 ANSWERS:

1. Virchow's node = palpable supraclavicular nodes [associated dx: stomach cancer]
2. Pancoast's = shoulder discomfort, Horner's syndrome [associated dx: apical lung tumors]
3. Lambert-Eaton = myasthenia [associated dx: small cell carcinoma]
4. Trousseau's = thrombophlebitis [associated dx: adenocarcinoma (breast, lung, prostate)]
5. Peau d'orange = edematous thickened breast skin [associated dx: late stage breast CA]





Pic sources: http://www.netterimages.com/image/10287.htm, www.studyblue.com, http://www.bmj.com/content/336/7656/1298?ijkey=kN/189nWkD8aw&keytype=ref&siteid=bmjjournals

Source: Medical Boards Step 2 Made Ridiculously Easy - Andreas Carl, MD

Heart Failure

Quick study material on heart failure:

LEFT SIDED

• dyspnea
• wheezing
• orthopnea
• S3/S4 gallop
• puLsus alternans

RIGHT

• peripheral edema
• nocturia
• JVD
• hepato/spleno-megaly

FUNCTIONAL CLASSES (1 = best, 4 = worst)

Pic source: http://www.remodulin.com/patient/diagnosing-pah.aspx
Source: Medical Boards Step 2 - Made Ridiculously Simple (Andreas Carl, MD)

Hematuria Workup

A diagnostic algorithm to consider when working up hematuria...

click on picture to enlarge

Source: Ferri's Best Test: A practical guide to clinical lab and medicine diagnostic imaging, Fred Ferri

Managing Shoulder Injuries

The American Family Physician is the peer-reviewed journal put out by the AAFP and they often have great stuff. This is an older article, but still incredibly relevant.

A shout out to my ortho roots...

Management of Shoulder Impingement Syndrome and Rotator Cuff Tears

New PA Student Site

Check out the new microsite dedicated to PA Students! I was part of the team that worked hard to put this together and the AAPA was an integral part of giving us the funding to get this up and running. It is a "one stop shop" that was created BY PA students FOR PA students!

Check it out. Write a blog entry for the site. Submit a new scholarship that you found that is relevant. The continued success of the site is dependent on YOU the PA student to help keep it alive with content!

See the About Us section to know where to send your content!

www.PAStudentEssentials.com

Approach to Volume Disorders, Part 3

Fluid Replacement Therapy

 I have also attached a chart that should be helpful in understanding when to give which type of fluid.

Family Practice Notebook

The FPNotebook site is a wealth of information - unfortunately- much of it is buried. They have changed their site a bit and added more advertisements which makes everything a little harder to find, but on there is still a lot of great info (especially under the tabs such as Derm and Nephrology).