Podcasts about Ondansetron

On this special episode of Tuesday Night IBS, we talk with the co-principal investigator, Alex Ford, MD, from Leeds University in the UK, about the ATLANTIS trial of Amitriptyline for irritable bowel syndrome (IBS) in primary care, which was funded by the Health Technology Assessment program of the National Institute for Health and Care Research and the TRITON trial using Ondansetron to manage irritable bowel syndrome with diarrhea.Dr. Alex Ford is a Professor and Honorary consultant gastroenterologist at St. James's University Hospital, Leeds, UK. His main interest is in the epidemiology, diagnosis, and treatment of disorders of gut-brain interaction, such as irritable bowel syndrome and functional dyspepsia. He is an Associate Editor for Alimentary Pharmacology & Therapeutics. He has published over 450 peer-reviewed articles, including original scientific papers in The Lancet, JAMA, BMJ, Gastroenterology, Gut, Archives of Internal Medicine, and The American Journal of Gastroenterology.

Metformin is a medication used in the management of diabetes. It can cause significant diarrhea, B12 deficiency, and in rare cases, lactic acidosis. Atorvastatin (Lipitor) is a statin medication used for cholesterol management. It lowers LDL and is associated with myopathy. Omeprazole is a PPI used for GERD and has drug interactions with citalopram and clopidogrel. Ciprofloxacin is a quinolone antibiotic used to treat gram-negative infections and UTIs. It carries numerous risks such as tendon rupture. Ondansetron is an antiemetic medication used in the management of nausea and vomiting. I discuss the prescribing cascade in relation to this medication.

On this special episode of Tuesday Night IBS, we talk with the co-principal investigator, Alex Ford, MD, from Leeds University in the UK, about the ATLANTIS trial of Amitriptyline for irritable bowel syndrome (IBS) in primary care, which was funded by the Health Technology Assessment program of the National Institute for Health and Care Research and the TRITON trial using Ondansetron to manage irritable bowel syndrome with diarrhea.Dr. Alex Ford is a Professor and Honorary consultant gastroenterologist at St. James's University Hospital, Leeds, UK. His main interest is in the epidemiology, diagnosis, and treatment of disorders of gut-brain interaction, such as irritable bowel syndrome and functional dyspepsia. He is an Associate Editor for Alimentary Pharmacology & Therapeutics. He has published over 450 peer-reviewed articles, including original scientific papers in The Lancet, JAMA, BMJ, Gastroenterology, Gut, Archives of Internal Medicine, and The American Journal of Gastroenterology.

Show notes at pharmacyjoe.com/episode929. In this episode, I'll discuss the incidence of torsades from low-dose ondansetron in peri-operative patients. The post 929: What is the incidence of torsades from low-dose ondansetron in peri-operative patients? appeared first on Pharmacy Joe.

This is the 32nd episode in my drug name pronunciation series.  Today, we're talking about ondansetron (Zofran).  I divide both drug names into syllables, tell you which syllables to emphasize, and share my sources. The written pronunciations can be helpful, so you can see them below and in the show notes on thepharmacistsvoice.com.   Ondansetron = on-DAN-se-tron Emphasize DAN  Source:  USP Dictionary Online   Zofran = ZOE-fran Emphasize ZOE Source:  My experience as a pharmacist   Thank you for listening to episode 278 of The Pharmacist's Voice ® Podcast!   To read the FULL show notes, visit https://www.thepharmacistsvoice.com.  Click the Podcast tab, and select episode 278.   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  Spotify  https://spoti.fi/3qAk3uY  Amazon/Audible  https://adbl.co/43tM45P YouTube https://bit.ly/43Rnrjt   Links from this episode USP Dictionary Online **Subscription-based resource USP Dictionary's (USAN) pronunciation guide (Free resource on the American Medical Association's website)  The Pharmacist's Voice ® Podcast Episode 276, pronunciation series episode 31 (tocilizumab-aazg) The Pharmacist's Voice ® Podcast Episode 274, pronunciation series episode 30 (citalopram and escitalopram) The Pharmacist's Voice ® Podcast Episode 272, pronunciation series episode 29 (losartan) The Pharmacist's Voice Podcast Episode 269, pronunciation series episode 28 (tirzepatide) The Pharmacist's Voice Podcast Episode 267, pronunciation series episode 27 (atorvastatin)  The Pharmacist's Voice Podcast Episode 265, pronunciation series episode 26 (omeprazole) The Pharmacist's Voice Podcast Episode 263, pronunciation series episode 25 (PDE-5 inhibitors) The Pharmacist's Voice Podcast Episode 259, pronunciation series episode 24 (ketorolac) 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

Amniotic Fluid Embolism is a devastating and rare complication of pregnancy. The A-OK protocol is commonly advocated for as a life saving therapy in this scenario.Dr Stephanie Martin reviews the case reports and discusses her opinions on the role of A-OK in AFE management.Go to www.amnioticfluidembolism.org for access to a free educational program on AFE.Case reports referenced:Wothe JK, Elfstrand E, Mooney MR, Wothe DD. Rotational Thromboelastometry-Guided Venoarterial Extracorporeal Membrane Oxygenation in the Treatment of Amniotic Fluid Embolism. Case Rep Obstet Gynecol. 2022 May 18;2022:9658708. doi: 10.1155/2022/9658708. PMID: 35646404; PMCID: PMC9132692.Long M, Martin J, Biggio J. Atropine, Ondansetron, and Ketorolac: Supplemental Management of Amniotic Fluid Embolism. Ochsner J. 2022 Fall;22(3):253-257. doi: 10.31486/toj.21.0107. PMID: 36189093; PMCID: PMC9477128.Berry A, Salcedo A, Riba C. Atypical amniotic fluid embolism successfully treated with a novel protocol: A case report. J Case Rep Images Obstet Gynecol 2022;8:100109Z08AB2022.Rezai S, Hughes AC, Larsen TB, Fuller PN, Henderson CE. Atypical Amniotic Fluid Embolism Managed with a Novel Therapeutic Regimen. Case Rep Obstet Gynecol. 2017;2017:8458375. doi: 10.1155/2017/8458375. Epub 2017 Dec 21. PMID: 29430313; PMCID: PMC5753013.

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

Contributor: Aaron Lessen MD Educational Pearls: A recent randomized controlled trial compared ondansetron 8 mg IV with droperidol 2.5 mg IV for the treatment of nausea & vomiting in the emergency department.  Overall, droperidol and ondansetron had similar primary outcomes in acute nausea control  Symptom improvement in 93% of patients receiving droperidol vs. 87% receiving ondansetron (P = 0.362) Secondary measures were, however, statistically significantly different between groups Patients needed fewer rescue/additional antiemetics in the droperidol group (16%) compared with the ondansetron group (37%); p = 0.016 Similarly, more patients in the droperidol group reported they achieved the desired effect of the medication (85% vs. 63%; p = 0.006) Patients receiving droperidol did experience increased drowsiness 40% in the droperidol group vs. 11% in the ondansetron group The trial did not assess the length of stay in the ED after administering medications, which is a potential avenue for future research. References 1. Philpott L, Clemensen E, Lau GT. Droperidol versus ondansetron for nausea treatment within the emergency department. EMA - Emerg Med Australas. 2023;(December 2022):605-611. doi:10.1111/1742-6723.14174 Summarized & Edited by Jorge Chalit, OMSII  

In this episode, we review the high-yield topic of Ondansetron⁠ from the Gastrointestinal section. Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets

In this episode, we review the high-yield topic of ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Ondansetron⁠⁠ from the Gastrointestinal section. Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets --- Send in a voice message: https://podcasters.spotify.com/pod/show/medbulletsstep1/message

In our 171st episode of Beyond the Bump, Dr Timmy is back in the poddy pod!! And he's here to talk about pregnancy myths versus facts. We hope you enjoy!!! When I'm pregnant, I can't: Drink coffee Eat soft serves Eat sushi? And I can't eat seafood because of the mercury Eat deli meats and soft cheese Eat runny eggs and/or eggs in general Pineapples can cause miscarriages so I should avoid them in pregnancy Avoiding foods during pregnancy leads to a greater risk of bub being allergic to that food I can have tiny bits of alcohol when I'm pregnant If I take Ondansetron or Zofran during pregnancy it increases the risk of my child being born with a cleft lip/palate Ultrasounds are bad for the baby I have to sleep on my side, not on my back during pregnancy Your baby's gender is impacted by the time in the cycle that you have sex Nausea is worse if you're having a girl There are different cravings during pregnancy based on gender? Sweet it's a girl. Savoury if it's a boy Carrying low means you're having a boy A faster heart rate is likely to be a girl and a slower one a boy Heartburn means your bub has lots of hair It's a good sign if I have nausea at the start of my pregnancy I should not do high intensity exercise during my pregnancy Hot baths, saunas and spas are dangerous when I'm pregnant I should be weighted at every antenatal appointment Can I do laser hair removal when pregnant? What about Botox and/or other cosmetic procedures? Can I dye or bleach my hair? Can I smoke/vape during pregnancy?   Resource links Quit Centre - Pregnancy and Maternal Health   Beyond the Bump is a podcast brought to you by Jayde Couldwell and Sophie Pearce! A podcast targeted at mums, just like you! A place to have real conversations with honest and authentic people.   Follow us on Instagram at @beyondthebump.podcast to stay up to date with behind the scenes and future episodes.    This episode of Beyond the Bump is brought to you by Le Purée: If you are interested in trying out Le Purees nutrient-dense meals and smoothies or you would like to gift a pregnant or postpartum mama, you can select from both a la cart and subscription!  Head to www.lepuree.com.au and use code BTB10 for $10 off!

Download the cheat: https://bit.ly/50-meds  View the lesson:     Generic Name ondansetron Trade Name Zofran Indication nausea/vomiting Action blocks effects of serotonin on vagal nerve and CNS Therapeutic Class antiemetic Pharmacologic Class 5-HT3 antagonist Nursing Considerations • administer slowly over 2-5 minutes – fatal QT prolongation and VTach, respiratory arrest • may cause headache, constipation, diarrhea, dry mouth • asses nausea and vomiting • assess for extrapyramidal symptoms • monitor liver function tests

Trade – ZofranClass – Antiemetic MOA – Binds and blocks a receptor for the brain chemical serotonin Indication – Prevention and treatment of nausea and vomitingContraindication – Use caution in hypokalemia, hypomagnesemia, cardiac arrhythmias Side Effects – headache, fatigue, diarrhea, dizziness, hypotension/HTN, Prolonged PR and QT intervals, Widened QRS, Bradycardia, tachycardia, syncope. DosageAdult: 4– 8mg IV, IO, POPedi: (2-16 years) 0.15 mg/kg IV,IO ( max dose 16mg)

Acute gastro-enteritis is een aandoening die bijna elk kind onder de 5 jaar wel een keer treft. In de tweede lijn is ondansetron effectief in het verminderen van braken. Anouk Weghorst belicht in deze podcast de voordelen van eenmalig voorschrijven van ondansetron in de eerste lijn.GerelateerdH&W | Eenmalige gift ondansetron is (kosten)effectief bij kinderen met acute gastro-enteritis

Wat al werkte in het ziekenhuis moet op de huisartsenpraktijk dat toch ook goed doen? Verminderd ondansetron in het verminderen van braken bij kinderen op de huisartsenpost? Luister naar een interview met Anouk Weghorst door Marco Krukerink.

Show notes at pharmacyjoe.com/episode690. In this episode, I’ll discuss the incidence of torsades from low-dose ondansetron in peri-operative patients. The post 690: What is the incidence of torsades from low-dose ondansetron in peri-operative patients? appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode690. In this episode, I’ll discuss the incidence of torsades from low-dose ondansetron in peri-operative patients. The post 690: What is the incidence of torsades from low-dose ondansetron in peri-operative patients? appeared first on Pharmacy Joe.

Welcome to Episode 12 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show links below: Ondansetron in Children: https://journalfeed.org/article-a-day/2021/isolated-vomiting-is-it-just-a-virus https://journalfeed.org/article-a-day/2021/does-ondansetron-impact-meaningful-outcome-in-preschoolers https://journalfeed.org/article-a-day/2020/maybe-ondansetron-rx-does-reduce-bouncebacks-in-ki Auricular Hematomas & Auricular Block: Martha's Video https://youtu.be/jND3_4SdQvU Martha's Blog https://www.theproceduralist.org/thecases/auricular-blocks-and-hematomas Auricular Hematoma's https://www.ncbi.nlm.nih.gov/books/NBK531499/ Jess Mason's video on auricular blocks https://www.youtube.com/watch?v=6ZiB_9eNpcA Auricular Hematoma Drainage https://www.youtube.com/watch?v=mXjQu26BlIg Langer's Lines https://dermnetnz.org/topics/skin-tension-lines Bolsters https://www.aliem.com/trick-of-trade-splinting-ear/ Latest Guidelines of Zoster / Shingles: CDC https://www.cdc.gov/shingles/index.html Merck Manual https://www.merckmanuals.com/professional/infectious-diseases/herpesviruses/herpes-zoster Facial Dermatomes https://www.ebmconsult.com/articles/anatomy-dermatomes-face AAFP - Shingles https://www.aafp.org/afp/2000/0415/p2437.html Gabapentin https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217335 The Usual Links: CCME www.ccme.org SGEM: www.thesgem.com The Proceduralist: www.theproceduralist.org Old Procedural Pause videos: https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx

Dr. Roland Engelbrecht is a family physician in British Columbia, Canada, who has dedicated his medical practice to addiction treatment. He is also a member of the Canadian Alcohol Use Disorder Society, founded by Dr. Jeff Harries.The goals of CAUDS include educating the public about alcohol use disorder and how it is a medical condition that deserves compassion, not stigma. CAUDS also works to educate healthcare providers and the public about proven medical treatments that are effective in helping people to overcome alcohol addiction.While previous episodes on this podcast have focused on the use of naltrexone in treating alcohol use disorder, there are other medical treatments which can be helpful, in addition to naltrexone, or as an alternative for people who cannot tolerate naltrexone. There are also people who do not respond well to naltrexone, so adding additional medication can sometimes be helpful.Now, that medication assisted treatment of alcohol use disorder is becoming more commonplace, mainly as a harm reduction method in the form of The Sinclair Method, it is important that patients and their doctors understand that there are additional treatments available that can help to make their program more effective, if needed.I hope that this podcast episode is helpful in providing useful information to patients who can share it with their doctors, and for doctors who are looking for additional resources to offer their patients. For more information on the topics discussed in this episode, please visit http://www.cauds.org/, and please follow CAUDS on social media.Twitter handle: @cauds_orgFacebook page: https://www.facebook.com/caudsorgAlso, for more great podcast episodes and articles, please visit https://therehab.com and https://drleeds.com.

In this latest episode of the Hot Topics podcast, Neal Tucker considers why the press have been attacking general practice and who stands to gain. We also look at new research in to giving anti-emetics for children with gastroenteritis, the accuracy of PHQ9 in the assessment of depression and what are safe levels of air pollution.ReferencesBMJ Air pollutionBJGP Ondansetron in children with gastroBMJ PHQ 9 accuracy

In this episode we speak to Anouk Weghorst who is a doctoral candidate in the Department of General Practice and Elderly Care Medicine, University of Groningen, Netherlands. Paper: Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trial https://doi.org/10.3399/BJGP.2021.0211 (https://doi.org/10.3399/BJGP.2021.0211) Ondansetron was found to be effective in reducing vomiting in secondary care, but this effect has never been evaluated in primary care. Based on the findings of this study, ondansetron use is effective in reducing vomiting from 42.9% to 19.5%, seems safe and is positively evaluated by parents. Therefore, ondansetron could be considered by general practitioners as an additional treatment in the management of dehydration due to acute gastroenteritis, when the child predominantly vomits. Future research should disentangle the key factors leading to hospital referrals and consider ways to administer ORT more effectively in primary care or at home.

It's the JournalFeed Podcast for the week of August 30 - September 3, 2021. We cover ondansetron impact in children, a case of pediatric ROSC post withdrawal of care and ethical issues, C. difficile testing in babies, how to really change physician behavior, and the landmark AAP guidelines for febrile neonates/infants.

Ondansetron (brand name Zofran) is a very common medication you'll see in the clinical setting, on your care plans, and sprinkled throughout nursing school exams. In this episode, we'll go through ondansetron using the Straight A Nursing DRRUGS framework. Click here for show notes and links! https://www.straightanursingstudent.com/episode163/

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

This episode covers ondansetron!

What is the most effective agent for relieving nausea and vomiting in the ER? The answer may surprise you…Please click HERE to leave a review of the podcast!References:All references for Episode 42 are found on my Read by QxMD collection

In this episode, I talk with Jenny Li, BSN, SRNA about using pre-procedural ondansetron to prevent spinal-induced hypotension in elective cesarean-sections. Ms Li is completing her Doctorate of Nursing Practice (DNP) at the University at Buffalo and structured her doctoral work around this topic. She received a Bachelor of Science in Psychology from University of […]

Show notes at pharmacyjoe.com/episode558. In this episode, I’ll discuss the use of haloperidol vs ondansetron for Cannabis Hyperemesis Syndrome. The post 558: Which is better for Cannabis Hyperemesis Syndrome – haloperidol or ondansetron? appeared first on Pharmacy Joe.

Quick Summary Ondansetron for Peds Gastro - Article Review of article in Annals of EM regarding treatment of pediatric gastroenteritis with ondansetron with outpatient prescription

This month we discuss Guidelines in EM: Mental health | Ondansetron take home in paeds gastroenteritis | Diarrhea and rehydration

Here is the JournalFeed Podcast for the week of July 20-24, 2020. We cover norepinephrine and the immune response, ondansetron and pediatric bouncebacks, scaphoid fractures, geriatric rib fractures, and pediatric bradycardia with poor perfusion vs PEA.

Medikament des Monats ? Ondansetron! Aber nicht gegen Übelkeit, sondern gegen Blutdruckabfall bei Section in Spinalanästhesie. Gibt es doch gar nicht? Doch gibt es viel, ausprobieren! Der Beitrag „titriert“ Ondansetron zur Sectio erschien zuerst auf pin-up-docs - don't panic.

Ondansetron is a widely medication for nausea and vomiting. Typically given in 4mg doses but it can have some very serious side effects such as transient blindness.

Here is the JournalFeed Podcast for the week of April 13-17, 2020. We cover MDCalc tools for Telehealth, emergency responders in crisis and how to help, two studies on benefit of ondansetron in children, and a pericarditis spoon-feed extravaganza. Special thanks to Lara Fesdekjian for writing theme music!

La Nausea ed il Vomito post intervento chirurgico, comunemente definite PONV, possono essere prevenute utilizzando farmaci antiemetici come l'ondansetron, il desametasone e il droperidolo. L'ondansetron va somministrato alla fine dell'anestesia generale. Il desametasone deve essere somministrato all'inizio dell'anestesia generale. Il droperidolo va somministrato alla fine dell'intervento chirurgico. L'ondansetron e il droperidolo possono prolungare l'intervallo QT.ISCRIVETEVI: https://bit.ly/2XalKPwSe vi interessano gli argomenti inerenti l'anestesia, la rianimazione e l'algologia, ISCRIVETEVI a questo canale YouTube ed al podcast "L'Anestesista" su iTunes e su Spotify.ISCRIVETEVI: https://bit.ly/2XalKPwCercatemi sul web all'indirizzo: https://www.marialuisaruberto.com

Ondansetron (Zofran) is a medication used for nausea and vomiting. In this episode, I lay out the pharmacology, adverse effects, drug interactions and more! Ondansetron has been reported to increase the risk of serotonin syndrome. I discuss this further on the podcast. Ondansetron can exacerbate QTc prolongation. Keep an eye out for patients who may have risk factors or be on other medications that can contribute to this. I discuss this further on this podcast. Ondansetron is often used for chemotherapy induced nausea and vomiting. I discuss this and other indications on the podcast.

I denne episode af FOAMmedicPHARMA serien taler vi om Midazolam. Vi har set på ambulancetjenestens nye antiepileptikum og hypnotikum. Mange regioner har indført Midazolam i stedet for Diazepam og derfor er det oplagt at se nærmere på det medikament. Vi forsøger os igen med en mere evidensbaseret tilgang til løsningen på vores case i et forsøg på at stimulere til kritisk tænkning når løsningen ikke er inden for de kendte instrukser. Abonner eller hent via iTunes, Podbean, TUNE IN, Spotify, StitcherRadio, Soundcloud eller hvor du henter dine podcast. Støt FOAMmedics arbejde med 5 eller 10 kr pr. podcast. Hvis du har lyst til at støtte vores arbejde med at lave lækker lyd og skrift så klik ind på 10er.dk og støt os med 5,10 eller 15 pr. podcast episode, så bliver vi så sindsygt stolte og glade. Eller klik på 10'er logo her under og en pop-up løsning kommer frem. DISCLAIMER Det her er vores fortolkning af det pågældende medikament, det er ikke den endegyldige sandhed og vi opfordre som altid til at være kritisk over for den viden man hører og selv tjekke op på relevant viden og fakta. Du vil muligvis høre information eller om tilstande vedr. et medikament, hvor du ikke har delegation til at benytte medikamentet, men som udelukkende bliver omtalt, for at vi kan blive klogere i processen.Denne podcast er ikke en erstatning for pro.medicin.dk eller vores lokale retningslinjer. Links og henvisninger Introen til dette afsnit er lavet af Tyler Christifulli fra FOAMfrat, tjek dem ud, de har masser af fedt materiale. Pro.medicin om benzodiazepiner (hypnotika) Pro.medicin om Sederende midler (Odontologisk medicinvejledning) Pro.moedicin om Midazlom Youtube videoer som beskriver: GABA , Benzodiazepiner, Fremmende og hæmmende nervesignaler Bøger: Paramedic Textbook - Mosby af Mick Sanders Medical Pharmacology at a Glance - 6 udgave Farmakologi - Inge Olsen Den Præhospitale Patient  - Kim Dalgaard, Kenneth Lücbke m.fl. FOAMmedicPHARMA QUIZ Spørgsmål og svar fra sidste episode om Ondansetron er Spørgsmål:Hvilket medikament vi medbringer i ambulancen, udover ondansetron, har også en veldokumenteret effekt på kvalme?Svaret: Tavegyl/Clemastin Vi har trukket lod blandt de rigtige besvarelser og Vinderen af Ondansetron quizzen er Imran Khan. Imran er Ambulanceassistent og der er en lækker FOAMmedic præmie på vej til ham. Stort tillykke vi kontakter Imran for nærmere information for levering af præmien. Spørgsmålet i quizzen i denne episode af FOAMmedicPHARMA om Midazolam er: I kølvandet på 9/11 forsøgte den amerikanske efterretningstjeneste CIA, med alle midler at finde og jage terrorister i både ind og udland. Historien her fortæller at læger ansatte af CIA, i perioden fra 2002 til 2007, forsøgte sig med forskellige medikamenter der kunne fungere som sandhedsserum, for at fravriste tilfangetagne potientielle terrorister viden og information, der kunne føre til flere anholdelser eller bremse eventuelle terrorangreb. Projektet, der blev kaldt “project medication” var aldrig blevet godkendt af justitsministeriet, men udført alligevel. Disse læger forsøgte sig blandt andet med midazolam. Men spørgsmålet er her: under hvilket handelsnavn benyttede lægerne i CIA midazolam? Kender du svaret på spørgsmålet så svaret i en mail med emnet Quiz til FOAMmedic.org@gmail.com

Author: Jared Scott, MD Educational Pearls: Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis) When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0) References Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

February and March Quick Summary February and March Podcast Articles   Ondansetron in pediatric n/v/d, Chest CT for elderly rib fractures, Management of Infectious Diarrhea, Antibiotics for elderly UTI, BVM during intubation, Blunt Thoracolumbar trauma evaluation, Gender and NSTEMI treatment, Predictors of Antibiotic Failure in Nonpurulent SSTI, Safety of PERC + YEARS in Patients with Low Probability of PE, POCUS for RD in the ED, Oral vs IV Antibiotics for Bone & Joint Infection, Impact of Scribes in the ED, EtO2 Monitoring to Assess Preox in ED RSI, Burnout in EM Residents, Predicting SBI in Febrile Infants < 60 days old.

I'm joined by Dr Charlie Powell to discuss abdominal migraine and associated syndromes - cyclical vomiting and benign paroxysmal vertigo. Debilitating, recurrent abdominal pain which is central, associated with pallor and being withdrawn in an otherwise well, thriving child. Associated with poor school attendance. Once red flags have been ruled out (see what0-18.nhs.uk) explore the history and consider this diagnosis. Charlie discusses excluding trigger foods such as chocolate, cheese, citrus and marmite, as these contain vasoactive amines. Moving on to medical management, consider pizotifen and propranolol for prophylaxis or tryptans for acute episodes in older children. Ondansetron can be used in cyclical vomiting. For cyclical vomiting support, Charlie recommends visiting cvsa.org.uk Please subscribe, leave a review

I denne episode af FOAMmedic podcasts er vi tilbage med PHARMA serien. Vi har set på Ondansetron som er ambulancetjenesten foretrukne antiemetikum. Vi har undersøgt om det virker på alle typer af kvalme, og så går vi lidt ind i hvordan man bør tænke, når man skal praktisere evidensbaseret medicin. Abonner eller hent via iTunes for iOS og for android via Stitcher. Nu også via TUNE IN DISCLAIMER Det her er vores fortolkning af det pågældende medikament, det er ikke den endegyldige sandhed og vi opfordre som altid til at være kritisk over for den viden man hører og selv tjekke op på relevant viden og fakta. Du vil muligvis høre information eller om tilstande vedr. et medikament, hvor du ikke har delegation til at benytte medikamentet, men som udelukkende bliver omtalt, for at vi kan blive klogere i processen.Denne podcast er ikke en erstatning for pro.medicin.dk eller vores lokale retningslinjer. Links og henvisninger Rekommandation ved amning og anæstesi DASAIM 2015 DASAIM Preoporative nuasea and vomitting 2016 Pro.medicin om serotoninantagonister Pro.moedicin om Ondansetron Bøger: Paramedic Textbook - Mosby af Mick Sanders Medical Pharmacology at a Glance - 6 udgave Farmakologi - Inge Olsen Den Præhospitale Patient  - Kim Dalgaard, Kenneth Lücbke m.fl. FOAMmedicPHARMA QUIZ Spørgsmål og svar fra sidste episode om Naloxon er Spørgsmål:I hvilken by blev naloxon først patenteret, af hvem og i hvilket år?Svaret: Naloxon blev patenteret i NY i 61 af Mozes og Fishman fra Company Sankyo. Vi har trukket lod blandt de rigtige besvarelser og Vinderen af Nacanti quizzen er Anders Petri. Anders er sygeplejerske på Amager hospitals akutmodtagelse. Stort tillykke vi kontakter Anders for nærmere information for levering af præmien. Spørgsmålet i quizzen i denne episode af FOAMmedicPHARMA er: Hvilket medikament vi medbringer i ambulancen, udover ondansetron, har også en veldokumenteret effekt på kvalme? Kender du svaret på spørgsmålet så svaret i en mail med emnet Quiz til FOAMmedic.org@gmail.com Støt FOAMmedics arbejde med 5 eller 10 kr pr. podcast. Hvis du har lyst til at støtte vores arbejde med at lave lækker lyd og skrift så klik ind på 10er.dk og støt os med 5,10 eller 15 pr. podcast episode, så bliver vi så sindsygt stolte og glade. Eller klik på 10'er logo her under og en pop-up løsning kommer frem.

Kieran Quinn is back on the Rounds Table this week with Michael Fralick, general internist at the University of Toronto. This week they are covering four articles in rapid-fire style on maternal first trimester ondansetron and fetal outcomes, assessment of outpatient antibiotic prescribing patterns, creatinine in the peri-partum period, and a pharmacist-led intervention for deprescribing. The ...The post Pregnancy & Prescription Pads: Maternal Ondansetron Use, Renal Function in Pregnancy and Assessing Prescribing and Deprescribing Patterns appeared first on Healthy Debate.

Kieran Quinn is back on the Rounds Table this week with Michael Fralick, general internist at the University of Toronto. This week they are covering four articles in rapid-fire style on maternal first trimester ondansetron and fetal outcomes, assessment of outpatient antibiotic prescribing patterns, creatinine in the peri-partum period, and a pharmacist-led intervention for deprescribing. The ... The post Pregnancy & Prescription Pads: Maternal Ondansetron Use, Renal Function in Pregnancy and Assessing Prescribing and Deprescribing Patterns appeared first on Healthy Debate.

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!  

Editor's Summary by Phil Fontanarosa, MD, Executive Editor of JAMA, the Journal of the American Medical Association, for the December 18, 2018 issue

The Landmarks in Oncology Pharmacy series returns with a review of 2 ondansetron studies from 1990, published simultaneously in NEJM.

Ondansetron is the most popular antiemetic and often gets used indiscriminately for all types of vomiting ... but how would we treat vomiting if all of a sudden there was no ondansetron? Zachary Repanshek, MD FAAEM, addresses this question. This talk was featured at the American Academy of Emergency Medicine’s 22nd Annual Scientific Assembly.

The post Ondansetron (Zofran) appeared first on NURSING.com.

This edition of PEMCurrents echoes a recent post on the PEMBlog and reviews the use of ondansetron in acute gastroenteritis. Specifically highlighting the reduction in risk of further episodes of emesis, need for intravenous fluids and immediate admission to the hospital.

Dr. Stephanie Harman, Director of Palliative Care at Stanford University Medical Center, reviews nausea in the context of cancer, as well as the range of treatment options to manage it.

Dr. Stephanie Harman, Director of Palliative Care at Stanford University Medical Center, reviews nausea in the context of cancer, as well as the range of treatment options to manage it.