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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Feb 8, 2014

Which is more effective for pain and fever control: Acetaminophen or Ibuprofen? Should a patient in the emergency department with upper GI pain be started on an H2 blocker or a proton pump inhibitor? Special guest Anand 'The Swami' Swaminathan joins ERCast to explore these and many more medical quagmires. 

Bonus segment: How can a medical students present themselves well during critical rotations? In this case, we are talking about emergency medicine rotations.

Rob Says

  1. Work hard, always be curious, donʼt stress getting out right on time
  2. Presenting patients is one of your critical skills as a medical student
  3. Get the Emergency Medicine Secrets book so you know a rational approach to common medical emergencies, and keep the EMRA ddx card/ book in your pocket
  4. Present to the attendings but don't be a kiss ass
  5. Present patients the same way each time. Be concise with pertinent positives and negatives. When you give your differential diagnosis,, ALWAYS starting with the life threats based on the chief complaint. Even itʼs a typical migraine, emergency medicine is in the business of ruling out the life threats. As one of my internal medicine colleagues says, EM is in the business  of 'not to lose'
  6. As attendings, we want to know that the student ʻgetsʼ emergency medicine

Swami Says

  1. Show up to work on time. By on time, I mean the Joe Lex on time – 15 minutes early
  2. Recognize when it’s too busy and go into helper mode. This means not taking patients primarily (which is more work for us). Starting IVs, do EKGs, draw blood, sew lacerations, etc.
  3. Work hard. It’s as simple as that. When I work, I rarely sit, I keep moving all time. I should see the same from the students.
  4. There are three unforgivable sins in emergency medicine – laziness, stupidity and arrogance. It's preferable to have none of these. If you have one, you may be able to squeak by. If you have two, you are a waste of space. 

Acetaminophen versus Ibuprofen

Perrott DA et al. Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain and fever: a meta-analysis. Arch Pediatr Adolesc Med 2004; 158(6): 521-6.

2004 meta-analysis - summarized the findings from 17 randomized, controlled trials comparing the two drugs in children <18 years of age. Three studies involved pain, 10 involved fever, and all 17 involved safety. 

Findings

1. Pain – no difference between ibuprofen 4-10 mg/kg vs. APAP 7-15 mg/kg

2. Fever – ibuprofen 5-10 mg/kg superior to APAP 10-15 mg/kg (at 2 hours and more pronounced at 4-6 hours)

15% more children were likely to have reduced fever with ibuprofen compared to acetaminophen. 

When selecting for studies using only the 10mg/kg dose of ibuprofen, there was a doubling of the effect in support of ibuprofen. 

Safety: there was no evidence that one drug was less safe than the other (or placebo). The authors determined that this data was inconclusive and that more large studies would be needed to identify small differences in safety 

Pierce CA et al. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44(3): 489-506.

First meta-analysis looking at the question in adults.

Qualitative review revealed that ibuprofen was more effective than acetaminophen for pain and fever reduction, and that the two were equally safe. 

From the quantitative data, the authors found that for pain, ibuprofen was superior in children and adults. For fever, ibuprofen was superior in children, but conclusions could not be made for adults due to insufficient data.

What about alternating acetaminophen and ibuprofen?

Malya RR. Does combination treatment with ibuprofen and acetaminophen improve fever control? Ann Emerg Med 2013; 61(5): 569-70.

1. Identified 4 studies that the author deemed high-quality and relevant to emergency practitioners.  

2. Three of the four studies found that the combination was more effective at reducing fever than either alone.

One study that looked at alternating regimens over 24 hours found that 6-13% of parents exceeded the maximum number of recommended doses (Hay, 2008). 

There is suggestion that the two drugs could act synergistically to cause renal tubular injury; however, acetaminophen and ibuprofen have different pathways of metabolism, and adverse effects in patients taking both have only been described in rare case reports.

EM Lyceum Review of APAP (acetaminophen) vs NSAIDS (ibuprofen). This review also includes a breakdown of PPIs vs H2 blockers, medical treatment for vertigo, and calcium channel blockers versus beta blockers for atrial fibrillation with rapid ventricular response (RVR)

Check out the RAGE podcast. In this episode of ercast, we discuss a recent round table on managing SVT (AVNRT) with verapamil versus adenosine.