Podcasts about ketorolac

Contributor: Ricky Dhaliwal, MD Educational Pearls:  Ketorolac and ibuprofen are NSAIDs with equivalent efficacy for pain in the emergency department Oral ibuprofen provides the same relief as intramuscular ketorolac IM ketorolac is associated with the adverse effect of a painful injection IM ketorolac is slightly faster in onset but not significant Studies have assessed the two medications in head-to-head randomized-controlled trials and found no significant difference in pain scores IM ketorolac takes longer to administer and has a higher cost Ketorolac dosing Commonly given in 10 mg, 15 mg, and 30 mg doses However, higher doses are associated with more adverse effects Gastrointestinal upset, nausea, and bleeding risk Studies have demonstrated equal efficacy in pain reduction with lower doses References Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017;70(2):177-184. doi:10.1016/j.annemergmed.2016.10.014 Neighbor ML, Puntillo KA. Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Acad Emerg Med. 1998;5(2):118-122. doi:10.1111/j.1553-2712.1998.tb02595.x Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Show notes at pharmacyjoe.com/episode993. In this episode, I'll discuss ketamine vs ketorolac for pain management in ED patients with chest trauma. The post 993: Ketamine vs Ketorolac for Pain Management in ED Patients with Chest Trauma appeared first on Pharmacy Joe.

The FDA has issued a proposal to remove a common decongestant in over the counter products; A follow-up study assesses the efficacy of a schizophrenia treatment; The FDA's Endocrinologic and Metabolic Drugs Advisory Committee panel takes vote on the potential of approving a new diabetes treatment; IV ibuprofen adverse reactions examined; And semaglutide found to improve liver fibrosis.  

In this episode of the St. Emlyn's podcast, hosts Iain Beardsell and Simon Carley share their insights from recent conferences, including Gateshead's RCEM scientific conference, Tactical Trauma 24 in Sweden, and the Premier Conference. They explore 'Goldilocks moments' for executing life-saving procedures in critical care, emphasizing optimal timing for interventions like thoracotomies. The episode also discusses innovative training methods like shadowboxing to enhance decision-making in high-stress medical scenarios. In addition, they review a significant trial on smoking cessation in emergency departments, highlighting its potential role in broader public health initiatives, including sexual health and HIV screening. Discussions also cover various pain management strategies, such as the use of intranasal vs. intravenous Ketorolac for renal colic. The hosts critique the traditional peer review process in medical research and advocate for open peer review to support equitable and accessible scientific publishing. 00:00 Introduction and Catching Up 02:07 The Goldilocks Moment in Critical Care 05:25 Training and Decision-Making in Emergency Procedures 07:23 Smoking Cessation in Emergency Departments 10:07 Challenges in Implementing Preventive Health Strategies 10:38 Successful Public Health Projects in Emergency Medicine 11:19 Exploring Alternative Interventions in Emergency Departments 11:52 Highlights from the Premier Conference 12:54 Intranasal Ketorolac for Pain Management 15:46 The Future of Peer Review in Medical Research 20:09 Concluding Thoughts and Upcoming Content

This is the 24th episode in my drug name pronunciation series.  Today, we're talking about ketorolac (Toradol®).  I have heard ketorolac pronounced three different ways.  How do you say it?   If you're new to my drug name pronunciation series, welcome! In this episode, I divide ketorolac and Toradol into syllables, explain which syllables you need to emphasize, and reveal the sources of my information.  Seeing the written pronunciations is helpful, so the written pronunciations are below and in the show notes on thepharmacistsvoice.com. Ke-TOR-a-LAC Emphasize TOR and LAC TOR gets the most emphasis TOR-a-DOL Emphasize TOR and DOL  TOR gets the most emphasis The purpose of my pronunciation episodes is to provide the intended pronunciations of drug names from reliable sources so you feel more confident saying them and less frustrated learning them. Thank you for listening to episode 259 of The Pharmacist's Voice ® Podcast! To read the FULL show notes, visit https://www.thepharmacistsvoice.com/podcast.  Select episode 259. Subscribe to or follow The Pharmacist's Voice ® Podcast to get each new episode delivered to your podcast player and YouTube every time a new one comes out!   Apple Podcasts   https://apple.co/42yqXOG  Google Podcasts  https://bit.ly/3J19bws  Spotify  https://spoti.fi/3qAk3uY  Amazon/Audible  https://adbl.co/43tM45P YouTube https://bit.ly/43Rnrjt Links from this episode USP Dictionary Online (aka “USAN”)  **Subscription-based resource USP Dictionary's (USAN) pronunciation guide (Free resource on the American Medical Association's website) The Pharmacist's Voice ® Podcast episode 254, pronunciation series episode 23 (Paxlovid) The Pharmacist's Voice ® Podcast episode 250, pronunciation series episode 22 (metformin/Glucophage) The Pharmacist's Voice Podcast ® episode 245, pronunciation series episode 21 (naltrexone/Vivitrol) The Pharmacist's Voice ® Podcast episode 240, pronunciation series episode 20 (levalbuterol) The Pharmacist's Voice ® Podcast episode 236, pronunciation series episode 19 (phentermine)  The Pharmacist's Voice ® Podcast episode 228, pronunciation series episode 18 (ezetimibe) The Pharmacist's Voice ® Podcast episode 219, pronunciation series episode 17 (semaglutide) The Pharmacist's Voice ® Podcast episode 215, pronunciation series episode 16 (mifepristone and misoprostol) The Pharmacist's Voice ® Podcast episode 211, pronunciation series episode 15 (Humira®) The Pharmacist's Voice ® Podcast episode 202, pronunciation series episode 14 (SMZ-TMP) The Pharmacist's Voice ® Podcast episode 198, pronunciation series episode 13 (carisoprodol) The Pharmacist's Voice ® Podcast episode 194, pronunciation series episode 12 (tianeptine) The Pharmacist's Voice ® Podcast episode 188, pronunciation series episode 11 (insulin icodec)  The Pharmacist's Voice ® Podcast episode 184, pronunciation series episode 10 (phenytoin and isotretinoin) The Pharmacist's Voice ® Podcast episode 180, pronunciation series episode 9 Apretude® (cabotegravir) The Pharmacist's Voice ® Podcast episode 177, pronunciation series episode 8 (metoprolol)  The Pharmacist's Voice ® Podcast episode 164, pronunciation series episode 7 (levetiracetam) The Pharmacist's Voice ® Podcast episode 159, pronunciation series episode 6 (talimogene laherparepvec or T-VEC)  The Pharmacist's Voice ® Podcast episode 155, pronunciation series episode 5 Trulicity® (dulaglutide)  The Pharmacist's Voice ® Podcast episode 148, pronunciation series episode 4 Besponsa® (inotuzumab ozogamicin) The Pharmacist's Voice ® Podcast episode 142, pronunciation series episode 3 Zolmitriptan and Zokinvy The Pharmacist's Voice ® Podcast episode 138, pronunciation series episode 2 Molnupiravir and Taltz The Pharmacist's Voice ® Podcast episode 134, pronunciation series episode 1 Eszopiclone and Qulipta

Elisabeth Stewart, MSN, MSNA, CRNA focused her Master of Science in Nurse Anesthesia project on the pharmacology of Toradol (ketorolac) and she's here today to tell us all about it. Elisabeth hails from Wisconsin, holds a BS in Mathematics with a pre-med concentration and engaged in HeLa cell cancer research prior to going to nursing […]

An amniotic fluid embolism (AFE) remains one of the most devastating conditions in obstetric practice. In today's episode, Sass and Jeremy review the pathophysiology, signs and symptoms, and management of this rare, but lethal condition. Included in the management of an AFE is the administration of a trio of medications known as A-OK (Atropine, Ondansetron, and Ketorolac). If you want to brush up on current management techniques for an AFE, hit play…because it's go time!   Here are some of the things we'll discuss in this episode: An example of this happening recently where Jeremy works. How the body reacts when an amniotic fluid embolism occurs. Who is most at risk for developing AFE? Signs and symptoms to pay attention to. The treatment and management of a patient suffering from AFE. What is the AOK treatment?   About our hosts: https://kpatprogram.org/about-the-school/faculty.html    Visit us online: http://beyondthemaskpodcast.com    Get the CE certificate here: https://beyondthemaskpodcast.com/wp-content/uploads/2020/04/Beyond-the-Mask-CE-Cert-FILLABLE.pdf   Help us grow by leaving a review: https://podcasts.apple.com/us/podcast/beyond-the-mask-innovation-opportunities-for-crnas/id1440309246

Visit: https://nursing.com/140meds to request your free copy of "140 Must Know Meds" Generic Name ketorolac Trade Name Toradol Indication pain Action pain relief due to prostaglandin inhibition by blocking of the enzyme cyclooxygenase (COX) Therapeutic Class nonsteroidal anti-inflammatory agents, nonopioid analgesics Pharmacologic Class pyrroziline carboxylic acid Nursing Considerations • may cause GI bleeding, Stevens-Johnson Syndrome, anaphylaxis, drowsiness • should not exceed 5 days of therapy • bleeding risk increased with garlic, ginger, and ginkgo • may decrease effectiveness of hypertensive medications and diuretics

Show notes at pharmacyjoe.com/episode828. In this episode, I’ll discuss a systematic review of the ketorolac dose ceiling for ED analgesia. The post 828: A Systematic Review of the Ketorolac Dose Ceiling for ED Analgesia appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode828. In this episode, I’ll discuss a systematic review of the ketorolac dose ceiling for ED analgesia. The post 828: A Systematic Review of the Ketorolac Dose Ceiling for ED Analgesia appeared first on Pharmacy Joe.

What's going down:   All about IUD insertions: what to know prior, how to mentally prepare, and the best ways to treat the pain if need be  The many uses of an IUD beyond preventing pregnancy  The 2 different types of IUDs: Hormonal vs. Copper, and what to expect from each   Discussing anxiety surrounding IUDs: uterine perforation, string placement, and hormonal concerns  The importance of doing your own research, speaking with your healthcare provider, and avoiding misinformation on social media   Clitorally, we can't believe how confused (some) men are about IUDs. Watch full TikTok here!   Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.   Social & Website  Tiktok: @drjenniferlincoln  Instagram: @drjenniferlincoln  YouTube: @drjenniferlincoln  Website: www.drjenniferlincoln.com    Resources   Grab a copy of my book HERE!  Obstetricians For Reproductive Justice    References  1. Whitworth K, Neher J, Safranek S. Effective analgesic options for intrauterine device placement pain. Can Fam Physician. 2020;66(8):580 581.   2. Gemzell-Danielsson K, Mansour D, Fiala C, Kaunitz AM, Bahamondes L. Management of pain associated with the insertion of intrauterine contraceptives. Hum Reprod Update. 2013;19(4):419-427. doi:10.1093/humupd/dmt022.   3. Laura Nguyen, Larkin Lamarche, Robin Lennox, Amanda Ramdyal, Tejal Patel, Morgan Black, Dee Mangin. Strategies to Mitigate Anxiety and Pain in Intrauterine Device Insertion: A Systematic Review. Journal of Obstetrics and Gynaecology Canada, Volume 42, Issue 9, 2020, Pages 1138-1146.e2, ISSN 1701-2163.  4. Lopez LM, Bernholc A, Zeng Y, Allen RH, Bartz D, O'Brien PA, Hubacher D. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2015 Jul 29;(7):CD007373. doi: 10.1002/14651858.CD007373.pub3. PMID: 26222246.  5. Karabayirli S, Ayrim AA, Muslu B. Comparison of the analgesic effects of oral tramadol and naproxen sodium on pain relief during IUD insertion. J Minim Invasive Gynecol. 2012 Sep-Oct;19(5):581-4. doi: 10.1016/j.jmig.2012.04.004. Epub 2012 Jul 4. PMID: 22766124.   6. Ngo LL, Ward KK, Mody SK. Ketorolac for Pain Control With Intrauterine Device Placement: A Randomized Controlled Trial. Obstet Gynecol. 2015 Jul;126(1):29-36. doi: 10.1097/AOG.0000000000000912. PMID: 26241253; PMCID: PMC4527080.   7. Mody SK, Farala JP, Jimenez B, Nishikawa M, Ngo LL. Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial. Obstet Gynecol. 2018 Sep;132(3):575-582. doi: 10.1097/AOG.0000000000002790. PMID: 30095776; PMCID: PMC6438819.  Learn more about your ad choices. Visit megaphone.fm/adchoices

Trade: Toradol Class: NSAIDMOA: inhibits the production or prostaglandins in inflamed tissue, which decreases the responsiveness of pain receptors. Indications: Moderately severe acute painContraindications: Patients with a hx of peptic ulcer disease or GI bleed, patients with renal insufficiency, hypovolemic patients, 3rd trimester pregnancy, nursing mothers, allergy to other nsaids, stroke or head trauma, having surgery within the next 7 days.  Side effects:  headache, drowsiness, dizziness, abdominal pain, dyspepsia, N/V, Diarrhea.Dosing:Adult IV 30mgIM 60mg Senior (65 and older)/ Pediatric < 50kgsIV 15mgIM 30mg

Download the cheat: https://bit.ly/50-meds  View the lesson: https://bit.ly/KetorolacToradolNursingConsiderations      Generic Name ketorolac Trade Name Toradol Indication pain Action pain relief due to prostaglandin inhibition by blocking of the enzyme cyclooxygenase (COX) Therapeutic Class nonsteroidal anti-inflammatory agents, nonopioid analgesics Pharmacologic Class pyrroziline carboxylic acid Nursing Considerations • may cause GI bleeding, Stevens-Johnson Syndrome, anaphylaxis, drowsiness • should not exceed 5 days of therapy • bleeding risk increased with garlic, ginger, and ginkgo • may decrease effectiveness of hypertensive medications and diuretics

In this podcast, Pat Chibbaro interviews Dr. Esperanza Mantilla-Rivas and Dr. Albert Oh about the article, “Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls." The article is published in the April 2022 issue of CPCJ. Click here to read the article.

Dr. Ebell and Dr. Wilkes discuss the POEM titled ' Ibuprofen, ketorolac, and diclofenac are equivalent for the treatment of acute nonradicular low back pain '

Lead Author, Chad F. Claus, DO, discusses his recent TSJ Outstanding Paper: The Effect of Ketorolac On Posterior Minimally Invasive Lumbar Spinal Fusion: An Interim Analysis from a Randomized, Double-Blinded, Placebo-Controlled Trial with Moderator Tejas Shah, MD. Access the article here: https://www.spineline-digital.org/spineline/november_december_2021/MobilePagedReplica.action?pm=2&folio=20#pg22

In terms of drugs, the world of anesthesiology can be mystifying to the outside world. Michelle Gaines, an expert nurse anesthesiologist, breaks down different aspect of drug use in anesthesiology, from legal to illegal. She explains the delicacy of mixing drugs to bring a patient out of anesthesia and explains while, though it is rare, some patients do wake up before the surgery is complete. Though laypeople would be surprised to learn that anesthesiology, as well as other realms of medicine, use non-FDA-approved drugs, Michelle highlights the immense value of drugs that have never received that approval. She also outlines the huge cost to a pharmacy company of getting the FDA to approve a drug. She candidly reveals the extent to which those who work in anesthesiology may become addicted to certain drugs and describes the medical and legal implications of working while under a drug's influence. Michelle also describes the long and laborious process by which a practitioner who has overcome an addiction can return to practice. Michelle and Pat also discuss the “gray” area of marijuana use and its effects on anesthesia. https://youtu.be/Gv_0QASVxHE Join me in this episode of Legal Nurse Podcast to learn about a Nurse Anesthesiologist - Who is at the Head of the Bed • What can cause confusion for LNCs studying anesthesia records? • How valid is the fear of waking up while still in surgery? • Why does medicine use non-FDA-approved drugs? • What's the cause of high drug abuse in the anesthesia world? • How can this abuse impact a medical malpractice case? 3 Simple Secrets to Getting Attorneys to Notice, Remember and Hire You – and Not at Substandard Rates a FREE Masterclass with Gerry Foster In this free masterclass, you'll gain concrete tips on how to establish your brand so that you stand out. You'll get the keys to excite, delight, and ignite your market, making it easier to get new attorney clients. Here's just a sample of what we'll cover in this incredible training: How to use effective tactics to build your LNC businessYour brand: the foundation of a successful LNC business!How to ensure your clients have a clear understanding of what makes you different and better than other LNCs who could work on this case... and much, MUCH More! Click here for the replay and a special free offer. Gerry generously offered to analyze your brand and give an hour of his time to brandstorm with you – yes, you might not know that word. Gerry will get on a Zoom call with you and guide you through an assessment of your brand. And all at no charge. Your Presenter Michelle Gaines, owner of Gaines Medical Consulting , provides expert consultation in reviewing medical records and testifying expert services in anesthesia related cases. She is a practicing certified registered nurse anesthetist (CRNA)> She started her career as an ICU nurse in a thirty-two bed medical/surgical ICU. Within two years of beginning her career she obtained her certification in critical care nursing (CCRN) and had preceptor and charge nurse duties. She attended graduate school at the University of Kansas where she obtained her Master of Science in Nurse Anesthesia. She presented her thesis, Narcotic Sparing Effects of Ketorolac in Cesarean Patients, at the annual national meeting of the AANA that year. Michelle started her career with an anesthesia group in central Texas. At that time she also taught paramedics at the associate degree level at Blinn College in Bryan, Texas . She also taught Advanced Cardiac Life Support (ACLS) to healthcare practitioners. During her twenty-six years in nurse anesthesia Michelle has worked in many different care settings including: tertiary care hospital, rural hospital, rural surgery center, suburban surgery center, suburban hospital and doctor office suites. Michelle's provider history includes delivering anesthesia for open heart surgery,

It's the JournalFeed Podcast for the week of November 22-26, 2021. We cover isolated vomiting in children, clinically diagnosing cauda equina, rapid MRI for pediatric headache, and IM ketorolac dosing for MSK pain.

An LNC must understand the specific nature of the roles different kinds of medical practitioners play in clinical settings. The subcategories of those who practice anesthesia have been undergoing rapid changes and evolution. New terminology may baffle the LNC reading medical data. Michelle Gaines, certified registered nurse anesthetist (CRNA), who is also an LNC, provides an expert analysis of the various roles and titles involved in the field to bring clarity to titles and abbreviations that may seem obscure. She describes the differences between a nurse anesthetist, a physician anesthesiologist, and an anesthesia assistant. In addition, she outlines the history of anesthesiology with some details that may surprise you. She gives special attention to the challenges of working in the field of anesthesiology during the epidemic. The particular physical proximity to the patient presents dangers that are aggravated by the lack of requirements in some areas that patients be tested for Covid or show proof of vaccination. The patient who receives anesthesia has no idea what goes on during an operation. Many others are unfamiliar with the anesthesiologic role. This podcast brings the realities of this challenging medical field into focus with valuable and pertinent information. https://youtu.be/b0hkwhqwirM Join me in this episode of Legal Nurse Podcast to learn about a Nurse Anesthesiologist - Who is at the Head of the Bed • How did the field of anesthesiology develop? • What does a nurse anesthesiologist do? • How does the relationship between the nurse anesthesiologist and the physician anesthesiologist work? • Why do legal nurse consultants, when they read medical records, need to pay particular attention to the category of anesthesiologist involved? • What is the role of an anesthesia assistant? • How has the role of a nurse anesthesiologist changed during Covid? 3 Simple Secrets to Getting Attorneys to Notice, Remember and Hire You – and Not at Substandard Rates a FREE Masterclass with Gerry Foster In this free masterclass, you'll gain concrete tips on how to establish your brand so that you stand out. You'll get the keys to excite, delight, and ignite your market, making it easier to get new attorney clients. Here's just a sample of what we'll cover in this incredible training: How to use effective tactics to build your LNC businessYour brand: the foundation of a successful LNC business!How to ensure your clients have a clear understanding of what makes you different and better than other LNCs who could work on this case... and much, MUCH More! Click here for the replay and a special free offer. Gerry generously offered to analyze your brand and give an hour of his time to brandstorm with you – yes, you might not know that word. Gerry will get on a Zoom call with you and guide you through an assessment of your brand. And all at no charge. Your Presenter Michelle Gaines, owner of Gaines Medical Consulting , provides expert consultation in reviewing medical records and testifying expert services in anesthesia related cases. She is a practicing certified registered nurse anesthetist (CRNA)> She started her career as an ICU nurse in a thirty-two bed medical/surgical ICU. Within two years of beginning her career she obtained her certification in critical care nursing (CCRN) and had preceptor and charge nurse duties. She attended graduate school at the University of Kansas where she obtained her Master of Science in Nurse Anesthesia. She presented her thesis, Narcotic Sparing Effects of Ketorolac in Cesarean Patients, at the annual national meeting of the AANA that year. Michelle started her career with an anesthesia group in central Texas. At that time she also taught paramedics at the associate degree level at Blinn College in Bryan, Texas . She also taught Advanced Cardiac Life Support (ACLS) to healthcare practitioners.

A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain

With the recent transition of IV acetaminophen from patent to generic, it's a good time to discuss MCHD's 2021 NAEMSP abstract describing our prehospital experience with IV tylenol for pain. If you've not looked into bringing this tool into your service, listen today to be convinced why IV Tylenol is an option worth considering across EMS. REFERENCES 1. Mahshidfar B, Rezai M, et al. Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial. Adv J Emerg Med. 2019 May 8;3(4):e37 2.Bijur PE, Friedman BW, et al. Randomized Clinical Trial of Intravenous (IV) Acetaminophen as an Adjunct to IV Hydromorphone for Acute Severe Pain in Emergency Department Patients. Acad Emerg Med. 2020 Aug;27(8):717-724.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medication for acute low back pain (LBP). It is unclear if the choice of NSAID impacts outcomes. We compared ibuprofen, ketorolac, and diclofenac for the treatment of acute, nonradicular LBP.

Migraines are no longer considered a vascular headache and now considered a neurologic disorder of dysfunctional nociceptive processing.  Diagnosis is completed clinically with no lab or imaging usually needed.  Treatment includes - Antidopaminergics (Metoclopramide & Prochlorperazine) - Triptans (Sumatriptan) - Nonsteroidals (Ketorolac).  Consider steroids to lessen the risk of recurrence.  Opioids should be avoided and are last line. Most patients don't need specialist referral.  To learn more, visit https://courses.ccme.org/course/em-prep

This week, we talk about amniotic fluid embolism (AFE) and the "A-OK" medication combination. Please click HERE to leave a review of the podcast!References:All references for Episode 49 are found on my Read by QxMD collection

It’s the JournalFeed Podcast for the week of Feb 1-5, 2021. We cover the accuracy of history, exam, labs, and POCUS for diagnosing giant cell arteritis; diltiazem vs. metoprolol for atrial fibrillation with rapid ventricular response; and IV ketorolac dosing for renal colic.

Show notes at pharmacyjoe.com/episode573. In this episode, I’ll discuss the ceiling dose of ketorolac for renal colic in the ED. The post 573: Ceiling dose of ketorolac for renal colic in the ED appeared first on Pharmacy Joe.

We talk about our holidays and Jason's back in the emergency room! Pics here: https://twitter.com/izzapizza_cos/status/1344481957732782081

Episode 17 – Tension HeadacheThe sun rises over the San Joaquin Valley, California, today is June 19, 2020. This week we welcomed a new group of residents who started on June 15, 2020. Welcome aboard, Drs. Amodio, Civelli, Grewal, Lorenzo, Lundquist, Martinez, Nwosu, and Viamontes. We are excited for you and all the experiences you will have in the next 3 years. On Jun 9, the USPSTF recommended to screen for unhealthy drug use all adults age 18 years or older. This a Grade B recommendation (moderate to substantial benefit). Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Screening in this case refers to asking questions about unhealthy drug use, not testing biological specimens(1).The search for the miraculous antiviral drug against COVID-19 continues. We previously mentioned remdesivir, which was granted Emergency Use Authorization (EUA) by the FDA on May 1, 2020 in the US. Another drug you should be aware of is avifavir. Avifavir is based on Favipiravir, originally sold in Japan as an antiviral medication to treat influenza. Avifavir has been approved to be used in Russia, and is being tested in the US and the UK as well. Let’s keep avifavir on our radar, if it works, we’ll surely know about it.Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “[Feedback], like rain, should be gentle enough to nourish a man’s growth without destroying his roots.” – inspired by Frank A. ClarkBeing corrected is not easy. It takes a lot of courage to accept that we may be wrong sometimes, and trying to fix our mistake requires diligence. Remember that your attendings are not trying to humiliate you (or at least the attending I know), but they are correcting you to help you succeed in your career. Today we have a resident who is excited to talk about his topic. Welcome, Dr Brito.1. Question Number 1: Who are you?I was born and raised in the center of the Cuban island. I had the opportunity to study and practice Medicine in my native country. After graduating from medical school, I completed my social service year in an underserved area on the beautiful north coast. Most of my patients were farm workers or fishermen. I also worked in the ER for 6 years before emigrating to the United States. Once in the US, and after years of preparation, I was accepted into the UCLA IMG Program in 2018, and the following year I matched in the Rio Bravo program.I like fish keeping, outdoor sports such as running, sports in general, my favorite Movie director is Pedro Almodovar. I also love jazz music, Miles Davis, and Chucho Valdes. 2. Question number 2: What did you learn this week?I learned about the treatment of Tension-type Headache (TTH).PREVENTIVE THERAPYProphylactic therapy ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions. Prophylactic treatment is indicated if headaches are frequent, long-lasting, or account for a significant amount of total disability. Such as, frequent episodic subtype (1 to 14 headache-days a month) and chronic subtype (>15 headache-days a month) Preventive therapy may be also indicated when acute therapy (such as acetaminophen and NSAIDs) fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications. Pharmacologic preventive therapies: Evidence of efficacy is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications - mirtazapine and venlafaxine, topiramate, gabapentin, tizanidine have limited data. Trigger point injections require more research. In contrast, SSRIs are not effective.  Dosing and duration of therapy: Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved. Benefit is often first noted only after four to six weeks of therapy. Avoid overuse of analgesic medication, in fact eliminate it, or preventive therapy will likely be ineffective. Measure the effectiveness of therapy by use of a patient headache diary. For example, amitriptyline at 10-12.5 mg nightly, and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated, maximum dose of 100 to 125 mg. TCA are associated with cardiac conduction abnormalities and arrhythmias. Before initiating treatment, patient should be screened, 40 years and older with EKG, younger than 40 can be screened by history for evidence of cardiac disease.  Behavioral therapies: Regulation of sleep, exercise, and meals. CBT, relaxation, biofeedback—These therapies may be suited for patients who prefer no pharmacologic treatment; those who have insufficient response to, or poor tolerance to pharmacologic treatments; pregnant, nursing, excessive use of analgesics; those who have significant stress or deficient stress-coping skills. Studies suggest treatment using biofeedback combined with relation therapy rather than other behavioral therapy options. Biofeedback: Electrical sensors connected to a monitor are hooked up to your body. The sensors measure one or more signs of stress. This can include heart rate, muscle tension, or body temperature. The measurements provide feedback about how your body responds to different stimuli. Patients learn to interpret those signals and control them.Other no pharmacologic therapies such as acupuncture which suggests any benefit is likely to be modest and Physical therapies with unproven benefits. ACUTE TREATMENTThe acute or abortive therapy of TTH ranges from nonpharmacologic therapies to simple and combination analgesic medications. In most cases, the treatment of TTH is largely self-directed using OTC medications without any input from a medical provider. Nonpharmacologic treatments include heat, ice, massage, rest, and biofeedback.  Precipitating factors include of TTH: Stress and mental tension are reported to be the most common precipitants. Other precipitants anxiety, major depression, overwork, Lack of sleep, Incorrect posture, etc. Controlling these triggers may help in the acute treatment of TTH.Medications: Given the available data, the recommended treatment is with simple analgesics such as NSAIDs or aspirin for patients with pure episodic TTH. Acetaminophen 1000 mg is probably less effective than NSAIDs or aspirin. Reasonable choices include ibuprofen (200-400), naproxen (220 or 550 mg) or aspirin (650 to 1000). For failing, diclofenac (25 to 100 mg). For those who cannot tolerate NSAIDs or aspirin, acetaminophen 1000 mg is the preferred choice. How to judge the success of acute treatmentReasonable goals:- Is the patient pain-free and functioning normally in two to four hours after treatment? - Does the treatment work consistently without routine headache recurrence? - Is the patient able to plan his or her day? (disability)- Is it tolerable?The treatment should be considered ineffective if two or more of these criteria are consistently not met. What to do in case of treatment failure Consider diagnosis of TTH is inaccurate, less likely secondary etiology, most likely migraine without aura Dx is correct but wrong medication choice, inadequate dose, timingMedication overusePatient has depression, and/or anxiety disorder. Other acute interventions: Combination analgesics containing caffeine (recommended in suboptimal response), butalbital and codeine (not recommended as initial therapy), Parenteral (chlorpromazine, metoclopramide (limited evidence), Ketorolac, Muscle relaxant (not recommended) 3. Question number 3: Why is that knowledge important for you and your patients? Tension-type headache is the most prevalent headache in the general population and the second-most prevalent disorder in the world. Yearly, prevalence rates for episodic TTH are approximately 80 % in men and women. Understanding the pathophysiology and clinical aspects of TTH is important for accurate diagnosis and optimum treatment. However, TTH is a relatively featureless HA, making it the least distinct of all the primary HA phenotypes. In addition, it is the least studied of all the primary HA disorders, despite having a high socioeconomic impact. Societal impact: The prevalence of TTH is greater than migraine and the overall cost of TTH is high. In one population study, persons with episodic TTH reported a mean of nine lost workdays and five reduced- effectiveness days, while persons with chronic TTH reported a mean of 27 lost workdays and 20 reduced-effectiveness days.  4. Question number 4: How did you get that knowledge?That knowledge came first from medical school, and second, after years of practicing Medicine. During those years, we as doctors, evaluate and manage a large number of patients with one of the most common medical complaints, headache. In terms of finding out more of what to do with patients, how to make them feel better, I had to look some stuff up. My trusty sources in clinic are 1) Up to Date, 2) Faculty, 3) Review/Journal articles. Not necessarily in that order. 5. Question number 5: Where did that knowledge come from?The information comes from multiple reliable medical sources such as “Frequent Headaches: Evaluation and Management” by Anne Walling, downloaded from the AAFP website, and “Tension-type headache in adults: Preventive treatment and Acute Treatment” in Up-to-Date. ____________________________Speaking Medical: CholuriaHi this is Harjinder Sidhu, I’m a 3rd-year medical student. I’m here to present the medical word of the week: Choluria. Has your patient ever inform you their urine color is brown (Coca-Cola color)? Choluria has 2 roots, “chol” and “uria.” “Chol” is the combination of bile and gallbladder. “Uria” is the presence of something in urine that should not be present. So choluria is the presence of bile in the urine. What causes the urine to become brownish in color? The presence of bile in urine is caused by an underlying liver disease such as cirrhosis, hepatitis and/or hemolysis. Choluria usually manifests when the serum levels of bilirubin are above 1.5mg/dl. Now that you understand what choluria is, in the future you can look out for our patients by asking any changes in urine as a sign of potential liver problems. Stay tuned for next week’s word of the week!____________________________Espanish Por Favor: Señale con un dedoHi this is Dr Carranza on our section Espanish por favor. This week I wanted to share a tool for a follow-up question. Not too long ago we learned that DOLOR means pain, and we learned about body parts like “cabeza” head, “rodilla” knee, “pecho” chest, etc. Next you will probably want to ask where the “dolor” exactly is, and to simplify things we can ask the patient to point with one finger to where it hurts. We can do this by saying “dónde” which means where, followed by “señale con un dedo”, which means point with one finger. “Señalar” means to point, and “dedo” means finger.I hope you can use this in your practice, “señale con un dedo”, and you can always ask nicely and add “por favor” which means please. Have a great week!Now we conclude our episode number 17 “Tension Headache”. Dr Brito briefly explained the treatment of tension headache. Lifestyle modifications are key in the treatment, and many non-pharmacological options are available with different degrees of evidence. Thinking about prophylaxis of tension headaches? Amitriptyline is likely a good choice, but remember the side effects as well. Dr Carranza taught us how to ask about location of pain with the phrase “señale con un dedo”, and then we remembered the word choluria, which is bilirubin in the urine. Stay tuned for more next week.This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Ariel Brito, Claudia Carranza, and Harjinder Sidhu. Audio edition: Suraj Amrutia. See you soon! _____________________References:Unhealthy Drug Use: Screening, June 09, 2020, US Preventive Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening“Avifavir, first COVID-19 drug from Russia: What you need to know”, MSN News, https://www.msn.com/en-ae/news/other/avifavir-first-covid-19-drug-from-russia-what-you-need-to-know/ar-BB14UKvN, accessed on June 15, 2020.“Biofeedback” by Healthline, https://www.healthline.com/health/biofeedback#procedure, accessed on June 15, 2020.Walling, Anne, Am Fam Physician. 2020 Apr 1; 101(7):419-428Taylor, Frederick R, “Tension-type headache in adults: Preventive treatment” (https://www.uptodate.com/contents/tension-type-headache-in-adults-preventive-treatment?search=tension%20type%20headache%20treatment&source=search_result&selectedTitle=2~108&usage_type=default&display_rank=2), and “Tension-type headache in adults: Acute treatment” (https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20type%20headache%20treatment&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1), Up to Date, accessed on June 15, 2020.

Show notes at pharmacyjoe.com/episode473. In this episode, I ll discuss the discrepancy between the labeled dose and the analgesic ceiling dose of IV ketorolac. The post 473: The discrepancy between the labeled dose and the analgesic ceiling dose of IV ketorolac appeared first on Pharmacy Joe.

We investigate the claim that administering ketorolac (Toradol) increases bleeding and should be avoided in surgeries for which there is concern for bleeding.  Claim 1. Administration of intraoperative ketorolac increases the bleeding time due to platelet inhibition Claim 2. Increased bleeding time translates to higher rate of surgical bleeding Claim 3. The magnitude of bleeding propensity attributable to ketorolac is clinically relevant Our guest today is Dr. Jamie Sparling of the Critical Care Division of the Massachusetts General Hospital.  Full show notes available at depthofanesthesia.com.  Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Bailey R, Sinha C, Burgess LP. Ketorolac tromethamine and hemorrhage in tonsillectomy: A prospective, randomized, double-blind study. Laryngoscope 1997;107:166–169. Cassinelli EH, Dean CL, Garcia RM, Furey CG, Bohlman HH. Ketorolac use for postoperative pain management fol- lowing lumbar decompression surgery: A prospective, ran- domized, double-blinded, placebo-controlled trial. Spine (Phila Pa 1976) 2008;33:1313–1317. Gobble RM, Hoang HL, Kachniarz B, Orgill DP. Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials. Plastic and Reconstructive Surgery 2014; 133(3): 741-755 Singer AJ, Mynster CJ, McMahon BJ. The effect of IM ketoro- lac tromethamine on bleeding time: A prospective, interven- tional, controlled study. Am J Emerg Med. 2003;21:441–443. Strom BL, Berlin JA, Kinman JL, et al. Parenteral ketoro- lac and risk of gastrointestinal and operative site bleed- ing: A postmarketing surveillance study. JAMA 1996;275: 376–382.   --

Guest Denise Morita, MD Host Paul Wirkus, MD, FAAP. Your questions are answered in episode 4: Non pharmacologic therapies, alternative therapies, when migraines just won't stop and the role of Ketorolac and narcotics. For show notes visit vCurb.com.

Show notes at pharmacyjoe.com/episode378. In this episode I ll: 1. Discuss an article about the safety of high-dose IV labetalol 2. Answer the drug information question “Why is oral ketorolac restricted to patients that are continuing a 5-day course that started as parenteral therapy?” The post 378: Is high-dose IV labetalol safe and why is oral ketorolac so restricted? appeared first on Pharmacy Joe.

Hear transcribed versions of author created video abstracts in this issue, which has a bit of a topic focus on High Grade Anal Intra-epithelial Neoplasia, though there are many more topics, including avimopam/ketorolac use, neuroendocrine tumors, IBD, ileostomy readmission and more!

In an effort to minimize narcotic analgesia and its potential side effects, anti-inflammatory agents offer great potential provided they do not interfere with bone healing. The safety of ketorolac administration after foot and ankle surgery has not been well defined in the current literature. The purpose of this study was to report clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. Our study found perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. This is the first study to examine the effect of ketorolac on radiographic time to union of ankle fractures. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.   To view the article click here.

Ms. Roberts and Dr. Pescatore not only dissect the April issue, but also call on the knowledge of pain expert Sergey Motov, MD, to discuss these game-changing articles: “The Cure for Back Pain Is Biting the Bullet” by Graham Walker, MD “Is Phenobarbital for Alcohol Withdrawal Ready for the Big Time?” by Leon Gussow, MD “TXA Superior to Packing for Epistaxis, and Patients Like It Better” by Dustin Ballard, MD, & David Vinson, MD “Rage against Renal Colic: Keep the Ketorolac, Maybe Morphine, Leave the Lido for Last” by Dan Runde, MD “Three Things You Should Know about Sickle Cell Disease” by EMedHome.com And much more!

This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_87_0_Final_Cut.m4a Download Leave a Comment Tags: Ketamine, Ketofol, ketorlac, POKER, Propofol, PSA Show Notes Take Home Points The POKER trial examined the difference between propofol and ketofol when it comes to adverse respiratory events.  They found no significant difference between the groups.  Given the increased risk of medication errors using two medication instead of one, you may want to avoid the mixture. Ketorolac has an analgesic ceiling effect lower than you may have thought.  When comparing IV doses of 10mg, 15mg and 30mg they found no difference in analgesic effect.  Given the risks of side effects may increase with higher doses, you may want to stick to the lower 10mg dose. RebelEM: The POKER Trial: Go All in on Ketofol? St. Emlyn's: JC: Is Ketofol with the hassle?

This week we discuss two recent journal articles - the POKER trial and the ketorlac analgesic ceiling https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_87_0_Final_Cut.m4a Download Leave a Comment Tags: Ketamine, Ketofol, ketorlac, POKER, Propofol, PSA Show Notes Take Home Points The POKER trial examined the difference between propofol and ketofol when it comes to adverse respiratory events.  They found no significant difference between the groups.  Given the increased risk of medication errors using two medication instead of one, you may want to avoid the mixture. Ketorolac has an analgesic ceiling effect lower than you may have thought.  When comparing IV doses of 10mg, 15mg and 30mg they found no difference in analgesic effect.  Given the risks of side effects may increase with higher doses, you may want to stick to the lower 10mg dose. RebelEM: The POKER Trial: Go All in on Ketofol? St. Emlyn’s: JC: Is Ketofol with the hassle?

Seemingly vague, but potentially dangerous... common, but possibly with consequences... ...or maybe just plain frustrating. Let's talk risk stratification, diagnosis, and management. Primary or Secondary? We can make headache as easy or as complicated as we like, but let's break it down to what we need to know now, and what the parents need to know when they go home. Primary headaches: headaches with no sinister secondary cause – like tension or migraine – are of course diagnoses of exclusion (cluster headache is exceedingly rare in children). Secondary headaches: headaches due to some underlying cause -- are what we need to focus on first. The list of etiologies is vast; here is just a sampling: How do I sort this out? Ask yourself three main questions: Is it a tumor? Is it an infection? Is it a bleed? Is it a tumor? Some historical features are high-yield in screening for signs or symptoms consistent with a space occupying lesion. Progression and worsening of symptoms over time Associated vomiting Pain only in the occiput Headache that is worse with Valsalva – ask if coughing, urinating, or defecating affects the headache Does this headache wake the child from sleep? Is it worse in the morning just after getting up? Conversely, the absence of some historical features may increase suspicion of a space-occupying lesion No family history of migraine No associated aura with the headache. Who needs neuroimaging? The short answer is, if the child has an abnormal exam finding, then obtain a non-contrast head CT in the ED.  If you’re worried enough to get imaging, then you should not feel great about sending him to an expedition to MRI. The reassuring point is that for a child with a normal neuro exam, we have time to figure this out. For the recurrent headache, outpatient MRI really is the way to go if at all possible – not only do we forgo unnecessary radiation, but MRI is more likely to reveal the cause – or rule out the concern. Medina et al. in Pediatrics reported on children with headache suspected of having a brain tumor. They stratified patients into low, intermediate, and high risk, based on clinical predictors from the history and physical. All had imaging. They then calculated probability of tumor in each group. The low risk group had a 0.01% probability of tumor. The intermediate group 0.4%, and the high-risk group had only a 4% probability of tumor. The take-home message is that in the stable patient with a normal neurologic exam and no red flags, time is on our side. The American Academy of Neurology's most recent guidelines, published first in 1994 and revised in 2004. 1. Neuroimaging on a routine basis is not indicated with recurrent headaches and a normal neurologic exam 2. Neuroimaging should be considered in children with an abnormal exam. 3. Neuroimaging should be considered in children with recent onset of severe headache, change in the type of headache, or associated features that suggest neurologic dysfunction Is it an infection? This is nothing new: if you think you need to perform a lumbar puncture, then you’re right. Go after the diagnosis when it meets your threshold for testing. The difficulty is in the child who just has a headache, plus or minus symptoms that may be viral syndrome. Dr Curtis et al. in Pediatrics did a systematic review of Clinical Features Suggestive of Meningitis in Children.  In the history, only obvious features were helpful in this study: bulging fontanel in the infant or neck stiffness in the older child.  Both increased the likelihood of meningitis by 8-fold. In the physical examination, the only reliable predictors in this study were poor general appearance or a change in behavior. You will catch those cases, because you would have tuned into meningitis early on -- especially in the unvaccinated. What about all-comers with fever and headache? The presence of a high fever (so greater than 40 °C) only conferred a positive likelihood ratio of 2.9, only marginally predictive. Reassuring is that for temperatures less than 40 °C, the LR was 1 for meningitis. In other words, a fever less than 40 °C was just as likely to be present with or without meningitis. Is it a bleed? Does this child have some underlying disorder? For example, sickle cell disease, hypertension, rheumatologic disease, or some other endocrine or metabolic disease, such as a mitochondrial disorder? In chronically ill children, consider cerebral sinus venous thrombosis, vasculitis, ischemia, or hemorrhage. Arteriovenous malformation (AVM) is the hemorrhage we fear the most. We really don’t know enough about arteriovenous malformations in the brain to say what is the typical presentation. They may be completely asymptomatic, until they rupture. Even the headache presentation is variable. Think, headache PLUS. New headache plus…vomiting. Headache plus…it’s unilateral and new for the patient. Headache plus…a new seizure. Headache plus…focal neuro deficits, that may be transient, due to a vascular steal phenomenon. Two illustrative cases of arteriovenous malformation: 1. An eleven-year-old girl presents to the ED with new headache, nausea, and vomting in the morning, then had a generalized seizure later that day, and presents with a low GCS. She was intubated, CT confirmed the AVM. She had a right frontal intraparenchymal bleed with midline shift. She underwent clot evacuation and extirpation of the intertwined arteries and veins. 2. A nine-year old girl presented to the ED with headache for two days, constant, then one day of nausea and vomiting. On presentation, she was altered, and had slow-reacting pupils. She also underwent evacuation, and only on histopathology did they find a single, arterialized vein. Primary Headache: Presumptive Impression Tension headaches are the most common in children and adults. As in adults, the tension headache is band-like, pressure, tighetening, and often associated with muscle aches in the neck and shoulders. Find out how often they occur, and whether there is any pattern of worsening symptoms, or if the symptoms seem to be related to sleep hygiene, video games, too much digital screen time. Also, screen for lack of exercise, poor diet, stress, and all of the other good questions you usually ask. Treat the cause or counsel about lifestyle modification, and offer PO hydration and an NSAID, like ibuprofen or acetaminophen (paracetamol). Non-pharmacologic techniques like heat packs, rest, stress relief, and a little TLC always help. Be careful not to encourage overreacting to the headache – sometimes we see a pattern of headache, attention, and more headache that can take root. Also look for overuse of medications, which may be the culprit in up to 50% of chronic headaches. Taking NSAIDs 3 or more times per week is associated with medication-induced headache, or cephalalgia medicamentosa. We often fail to identify migraine headaches in children in the ED, likely for two reasons: prevalence of migraine increases with age, and children don’t present exactly like adults. Stewart et al. in Neurology, report a prevalence of migraine in children that increases with age: 3 to 7 years of age was 2%; 7 to 11 years of age, 7%; and 11 to 20 years of age, 20% Pearl: migraines are most commonly bilateral and temporal in children.  They resemble "adult" tension headaches, but are much more severe. We may not be able to sort this out in the ED.  The point here is that migraines in children are more common that we may expect, and they can interfere with school performance, with social development, or even with family dynamics and overall stress burden. Primary Headache Diagnosis: Not (Usually) "Our Thing" You noticed that we treated before we knew exactly the etiology; such is Emergency Medicine. We may not be able to make a specific, definitive primary headache diagnosis in the ED, but we should be aware of the criteria to help counsel patients and families. Tension headache is the most common, but it requires multiple, similar episodes: Migraine headache (without aura) requires less episodes, but more specific features: An aura is a fast-pass to diagnosis of migraine:   Primary Headache Management So how do we treat primary headaches? If you feel this is a mild tension headache, fluids by mouth and a simple NSAID are probably all that is needed, in addition to a heaping dose of reassurance.  Ibuprofen (10 mg/kg/dose q 6h, up to 600 mg) for a short course has the most evidence basis.  Acetaminophen (paracetamol) (15 mg/kg/dose q6 h) for a short course may also be given. Abortive treatments with the triptans may have been tried at home, but if they are coming to see us, we are past the point where triptans will be helpful. For the primary headache that is resistant to NSAIDs, IV therapy may be considered. If you’re going for IV, a nice evidence-based migraine cocktail is the following: 1. A bolus of 20 ml/kg of normal saline, up to a liter 2. Ketorolac (0.5 mg/kg; max, 30 mg) 3. Diphenhydramine (2 mg/kg; max, 50 mg) 4. Prochlorperazine (0.1 mg/kg; max, 10 mg) Dr Kaar et al. in Pediatric Emergency Care evaluated the safety and efficacy of their institution’s standardized pediatric migraine practice guideline in the emergency department, which used ths cocktail, based on the best evidence available. In their retrospective chart review, they found the average visual pain scale drop from 7.8 to 2.1 There were no adverse events reported. So, really you can treat children with migraines very similarly to adults. Other treatments on the horizon (still under investigation) in children include IV adjuncts such as magnesium, valproic acid, and dexamethasone. Aftercare and Recurrence Prevention For everyone who is going home, take just a moment to talk about the importance of sleeping well, eating well, getting exercise, limiting digital screen time, and trying to improve ways of dealing with stress. When all else fails, and the parent has “heard it all”: get them started on a headache diary. Take a piece of paper, fold it in half, and start a template for them to work on in a spiral notebook.  Start a sample entry for them, with the date and time the headache started, what it felt like, what was happening just before, what made the headache better, any dose of medications given, how long it lasted, and what the patient did after. There are even free apps that will track the headache pattern. This is the first thing a neurologist will start them on – and it’s sometimes a selling point to the parent that the time spent waiting for a referral to a neurologist is not waste – they will actually be in better shape and can move things along faster.  It also gives them some sens of control of what can be a draining situation. Summary and Mental Road Map If you were thinking meningitis or acute bleed, especially with fever or meningismus, get a CT first if you see signs of increased intracranial pressure, or if there is an abnormal neuro exam. Otherwise go straight to the lumbar puncture (LP). In the afebrile child with a normal exam, give symptomatic relief, briefly counsel them, and arrange for follow-up. In the afebrile child with an abnormal exam, obtain a CT in the ED. If negative, either admit for MRI if you are still concerned, or consider LP for idiopathic intracranial hypertension (pseudotumor cerebri). Talk with parents early about expectations, and offer them some friendly advice on prevention. Refer patients to the primary care provider or neurologist if the presentation is more involved. After a good history and physical examination in the ED that results in no red flags, we have time on our side. Help the family through the process by explaining the next steps and what can be done in the meantime. Compassion and a plan: sometimes these are our most powerful allies.   References Ajiboye N et al. Cerebral Arteriovenous Malformations: Evaluation and Management. Scientific World J. 2014; vol 2014. Bachur RG, Monuteaux MC, Neuman MI. A comparison of acute treatment regimens for migraine in the emergency department. Pediatrics. 2015 Feb;135(2):232-8. doi: 10.1542/peds.2014-2432. Chiappedi M, Balottin U. Medication overuse headache in children and adolescents. Curr Pain Headache Rep. 2014 Apr;18(4):404. doi: 10.1007/s11916-014-0404-9. Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010;126(5):952-60. Gonzalez LF, Bristol RE, Porter RW, Spetzler RF. De novo presentation of an arteriovenous malformation. Case report and review of the literature. J Neurosurg. 2005 Apr;102(4):726-9. Kaar CR, Gerard JM, Nakanishi AK. The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting. Pediatr Emerg Care. 2016 Jul;32(7):435-9. doi: 10.1097/PEC.0000000000000525. Lewis DW, Ashwal S, Dahl G, Dorbad D, Hirtz D, Prensky A, Jarjour I; Quality Standards Subcommittee of the American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002 Aug 27;59(4):490-8. Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S; American Academy of Neurology Quality Standards Subcommittee; Practice Committee of the Child Neurology Society.Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society.Neurology. 2004 Dec 28;63(12):2215-24. Medina LS, Kuntz KM, Pomeroy S. Children With Headache Suspected of Having a Brain Tumor: A Cost-Effectiveness Analysis of Diagnostic Strategies. Pediatrics. 2001;108(2):255-63. Richer L, Billinghurst L, Linsdell MA, Russell K, Vandermeer B, Crumley ET, Durec T, Klassen TP, Hartling L. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database Syst Rev. 2016 Apr 19;4:CD005220. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. JAMA. 1992;267:64-69. Tascu A et al. Spontaneous intracranial hemorrhage in children – ruptured lobar arteriovenous malformations: report of two cases. Romanian Neurosurgery. 2015; 29(23) 1: 85-89. This post and podcast are dedicated to Mark Wilson, PhD, BSc, MBBChir, FRCS(SN), MRCA, FIMC, FRGS for his #FOAMed generosity, candor, humility, and dedication to the care of the acutely ill and injured. Thank you. Pediatric Headache Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone. Oral Acetaminophen (Tylenol) Give every 4-6 hours Regular strength – 325mg Extra strength – 500mg Maximum Daily Dose – 3000mg Oral Ibuprofen (Advil) NSAID Give every 4-6 hours Regular strength – 200mg Therapeutic Ceiling – 400mg Oral Hydrocodone-Acetaminophen (Vicodin, Norco) Give ever 4-6 hours Common doses – 5-325mg, 7.5-325mg, […]

Generic Name ketorolac Trade Name Toradol Indication pain Action pain relief due to prostaglandin inhibition by blocking of the enzyme cyclooxygenase (COX) Therapeutic Class nonsteroidal anti-inflammatory agents, nonopioid analgesics Pharmacologic Class pyrroziline carboxylic acid Nursing Considerations may cause GI bleeding,… The post Ketorolac: Toradol (nonsteroidal anti-inflammatory agents, nonopioid analgesics) appeared first on NURSING.com.