Morphine Equianalgesic Dose Chart in the Emergency Department.

Audience: The lecture and infographic are targeted towards Emergency Medicine physicians and residents. Introduction: Pain is the most common presenting symptom in the emergency department.1 Various classes of medications are used to treat acute and chronic pain. Specifically, opiate medications are often used to relieve moderate to severe pain. About 20% of patients presenting with the chief complaint of non-cancer pain receive an opioid prescription.2 Since there are many different types of opiates, conversion between one opioid to another has provided a great challenge in terms of addressing the balance between adequately controlling patients' pain and preventing serious adverse effects. The lack of a readily available standard opiate equivalent guide and physicians' limited knowledge base about morphine milligram equivalents may contribute to medication errors, insufficient treatment, addiction, and overdose. Educational Objectives: The primary aim of this study was to educate residents and attending physicians about opiate equivalent medications, medication metabolism, provide usual dosages, and to provide a standardized method for converting between various opiate medications in the emergency department (ED). By the end of this session, the learner will be able to: 1) define the term, "morphine milligram equivalents;" 2) describe the relative onset and duration of action of different pain medications often used in the emergency department; and 3) convert one opioid dose to another.Additionally, we aimed to evaluate the efficacy of the lecture and the infographic in increasing physicians' knowledge base of opioid medications and standardize the method of prescribing and converting between opioids in the ED. We designed and placed a simple, eye-catching infographic in the University of California, Irvine Emergency Department that depicted information pertaining to morphine equivalents and pharmacological properties of the opioids. We then presented a lecture on morphine equianalgesic doses, metabolism, and method for conversion between medications. In order to evaluate the functionality of the lecture and chart, we administered multiple surveys to ED providers pre- and post-lecture and placement of the chart in the ED. Our lecture and infographic included up-to-date literature and considered dose reductions, cross tolerance, and patient comorbidities. We designed the infographic to be visually appealing and simple for ease of use in a busy ED environment. Educational Methods: A lecture was designed to educate emergency department physicians and residents on the properties, metabolism and techniques for conversion between various opioid medications. Following the lecture, we walked through an example question with the participants. The lecture was presented at an Emergency Department conference. Research Methods: This lecture was presented at emergency medicine residency grand rounds. To evaluate the efficacy of our chart and educational lecture, we implemented a pre-presentation survey consisting of questions related to opiate conversions, metabolism, and medication characteristics without the help of the chart. After the presentation participants were once again asked to fill out the same set of questions on a post-presentation survey with the help of the chart. The effectiveness of the lecture and infographic was assessed by comparing participants' scores between the pre-presentation survey and post-presentation survey. A second post-presentation survey with the same set of questions was also sent out about 7 months after the presentation, to assess for retention of the information presented during the lecture. The responses were kept anonymous, though participants were asked for their level of training and four screening questions for the purpose of matching individual responses between the pre-presentation, initial post-presentation, and 7-month post-presentation surveys. Results: Seven initial post-presentation survey responses were matched to pre-presentation survey responses, while five 7-month post-presentation survey responses were matched to pre-presentation survey responses. Only one participant filled out all three surveys; this participant was found to have increased in score from pre-presentation survey (4/10) to immediate post-presentation survey (10/10), but decreased in score at the 7-month post-presentation survey (8/10). Five of the participants who filled out both the pre- presentation survey and immediate post-presentation survey showed improvement in their scores, one participant received the same score on both surveys, and one participant had a decrease in score. Between the five participants who filled out the pre-presentation survey and the 7-month post-presentation survey, one participant showed an increase in scores, two participants received the same score each time, and two participants decreased in scores. Discussion: Overall, the educational content and infographic allowed for improvement in a majority of the participants' scores between the pre-presentation survey and immediate post-presentation survey. However, it seems that retention of knowledge gained by the presentation waned as time passed, which manifested in most participants showing a decrease or no change in score between the pre-presentation survey and the 7-month post-presentation survey. In other words, through implementation of the infographic in the Emergency Department and educational lecture, we learned that the presentation and the walk-through of an example question contributed to immediate retention of knowledge of morphine equivalents. However, long-term retention of the knowledge about morphine equivalents was lacking. Given the small sample size of eleven participants, we are unable to definitively conclude whether this infographic and lecture are overall effective in improving knowledge, retention of knowledge, and change in clinical management. However, our results suggest that further larger studies could be conducted with the infographic and presentation as useful tools to advance EM physicians' knowledge and awareness of morphine milligram equivalents. Therefore, our hypothesis still stands that this infographic and lecture are useful tools that other EM programs could use and conduct studies to evaluate improvement in their learners' knowledge. The main takeaways are that educational lectures and visually-appealing graphics are able to enhance physicians' understanding of morphine equianalgesic doses in the immediate period after exposure, but must also be conducted with consistent follow-up to improve preservation of knowledge. Topics: Morphine milligram equivalents, morphine equianalgesic doses, opioids, opiates, infographic.

A Case Report of Epiglottitis in an Adult Patient.

Epiglottitis is historically known to be a disease of childhood. However, since the implementation of the Haemophilus influenzae type B vaccination, there has been an increasing incidence within the adult population. This is a case report of a 36-year-old male who presented to the emergency department (ED) in severe respiratory distress with complaints of a sore throat, shortness of breath, odynophagia, dysphagia, and hoarseness. Physical exam revealed biphasic stridor, tachycardia, tachypnea, and an erythematous uvula. Imaging of his neck revealed findings consistent with epiglottitis containing nonspecific air. The patient was rapidly intubated, started on broad spectrum antibiotics and dexamethasone. He was admitted for intensive medical management with Otolaryngology consultation. This case report highlights the importance of rapid recognition and diagnosis of epiglottitis in an adult population to prevent morbidity and mortality. Topics: Epiglottitis, stridor, odynophagia, dysphagia, Haemophilus influenzae, group C streptococci, thumb-print sign, intubation.

Lung Masses as a Presenting Sign of Disseminated Cryptococcus.

Cryptococcosis is an invasive fungal disease that most commonly affects immunocompromised individuals, typically causing pulmonary and central nervous system (CNS) symptoms. The fungus that causes cryptococcosis, Cryptococcus, is globally disseminated and often transmitted through bird droppings. The two most frequent and pertinent species responsible for clinical infections in humans include Cryptococcus neoformans, which has been known to cause the majority of cryptococcosis globally until recently, during which Cryptococcus gattii has been identified and reported more frequently. A 54-year-old male with a history of renal transplant on chronic immunosuppressants and type 2 diabetes mellitus was found to have multiple lung masses within the right upper and right lower lobes. He had also been experiencing syncope, multiple falls, worsening headaches, tinnitus, diplopia, and ongoing weight loss. The patient underwent a percutaneous biopsy of one of the lung masses in addition to a lumbar puncture (LP), both of which revealed positive cryptococcus antigen confirmed to be C. gattii. The patient was started on amphotericin B and flucytosine to treat cryptococcal meningitis. Despite treatment, his condition continued to worsen, necessitating daily therapeutic LP and temporary placement of a lumbar drain. Once his symptoms were better managed, he was discharged from the hospital but has continued to have serial LPs outpatient while concurrently taking fluconazole to prevent reaccumulation of cerebrospinal fluid (CSF) and recurrence of symptoms.  This report describes a unique presentation of disseminated C. gattii infection presenting as multiple lung masses and the subsequent management of CNS cryptococcosis.

Bladder Diverticulum-A Case Report.

A bladder diverticulum can be the consequence of a congenital abnormality or acquired as a result of trauma, infection, or outlet obstruction. Many are asymptomatic, but some may present with complications such as urinary tract infection, hematuria, or urinary retention. A 76-year-old male presented to the emergency department (ED) for the second visit in one week with a chief complaint of urinary retention and lower abdominal pain. He had not voided since the prior night, when he had presented to the ED for the same compliant. During his initial visit, his symptoms were relieved by insertion of an in-&-out foley catheter. Point of Care Ultrasound (POCUS) of the bladder showed the appearance of two enlarged vertically aligned "bladders" with a central connection, concerning for a bladder diverticulum. Patient's cause of bladder diverticulum was found to be secondary to outlet obstruction, specifically benign prostatic hypertrophy (BPH). An indwelling foley catheter was inserted, and the patient was discharged home with instructions for urology follow up. The purpose of this report is to describe an anatomical anomaly of a bladder diverticulum presenting incidentally on Point of Care Ultrasound during routine workup of urinary retention. Topics: Urinary bladder diverticulum, urinary retention, benign prostatic hypertrophy, POCUS, case report.