Topics in Emergency Medicine, Pain Management, and
Palliative Care

These set of lectures is designed to provide important updates in emergency medicine with a focus on anticoagulation and the management of venous thromboembolism as well as bleeding emergencies that may occur in patients on new oral anticoagulants as well as those that present with bleeding peri-procedure. In addition, the relationship between patient safety indicators and quality metrics are discussed both as a separate lecture but also as a theme throughout other lectures - for example, how to approach fluid resuscitation in the context of changing sepsis core measures.

We will review the evolving role of the ED in the diagnosis of HIV and treatment of HIV related illnesses. In addition, a lecture on HCV considers a potential role for the ED in screening and linkage but also on the syndemics of HCV and other disease such as coronary artery disease and diabetes. The colocation of a burgeoning HCV epidemic in young people and the relationship to that epidemic and the ongoing opioid crisis is also discussed. Finally, a quality improvement approach will also be used to consider updated CDC guidelines for the management of STIs.

Opioids are commonly used for pain and opioid rotations are necessary in 20-40% of patients on opioid therapy because of side effects or lack of response. The next generation of conversion metrics will involve opioid utility which looks at risks versus benefits.

Knowing opioid equianalgesia is critically important and utility will help clinicians choose safer opioids. Certain opioids, such as nalbuphine and buprenorphine are finding a niche in pain management and it is important that clinicians know the pharmacology and clinical advantages to both. Methadone dosing has changed and the way it is being used has also been changed and levorphanol is making a come back.

A major issue that has arisen recently is whether cannabinoids should be combined with opioids or gabapentin with opioids. Knowing the pros and cons of these combinations will improve pain management. We have learned much about the long-term potential risks of opioids besides addiction which clinicians should be aware. Difficult pain cases from real life are useful tools to discuss how to manage such problems in a group. Palmitoylethanolamide is a cannabimimetic nutraceutical which is an analgesic for neuropathic pain but also arthritis. There is a rising interest in this agent as an analgesic or adjuvant to standard analgesics.

Topics:

1. Sepsis Updates
   • Learn EBM supporting CMS Sep-1 Bundle and areas where data is still lacking to further guide therapy
2. Updates on patient quality, experience, safety and satisfaction
   • Survey of the quality landscape including reviews of patient safety indicators and important hospital metrics
3. Venous Thromboembolism
   • Diagnosis and treatment of VTE including DVT, SVT, and PE
4. HIV
   • Review of HIV
   • Management of HIV
   • Linkage to care and treatment strategies in patients with HIV
5. HCV
   • Extra hepatic manifestations of HCV
   • Linkage to care and treatment strategies in patients with HIV and HCV
6. Bleed Management
   • Review of non-traumatic and traumatic bleed management
   • Consideration of bleeding on anticoagulant medications
7. Management of Sexually Transmitted Infections (STIs) and other atraumatic GU pathology
   • Review of CDC guidelines for STI management
   • Review of common STIs
   • Review of other atraumatic GU emergencies
8. Opioid Conversions
   • Clinicians will be able to use an updated conversion table and switch opioids successfully in practice.
   • Clinicians will have a basic understanding of the concept of opioid utility.
9. Nalbuphine and buprenorphine
   • Clinicians will be able to clinically use nalbuphine and buprenorphine in clinically appropriate situations
10. Methadone and levorphanol
    • Clinicians will understand the pharmacology and the different dosing strategies of these two opioids
11. Opioids in combination with cannabis and with gabapentin
    • Clinicians will understand the strength of evidence and potential detriments to combining cannabis or gabapentin to opioid therapy.
12. The Balance of Chronic Opioid Therapy
    • Clinicians will be aware of the multitude of long-term detriments to opioid therapy
13. Palmitoylethanolamide as an Analgesic
    • Clinicians will be able to use palmitoylethanolamide as an analgesic
14. Difficult Pain Cases
    • Clinicians will be able to manage difficult pain phenotypes such as tenesmoid pain, ischemic extremity pain, choose the appropriate opioids in organ failure and manage chronic persistent opioid dependence.