Lesson Plan #8 Title: What Are My Options, Doc?

Performance Objective: Given a complete case study with 2 or more vi-

able treatment options, the students will use problem solving sub-skills to

create an outline for an argument they will use to defend both treatment se-

lections, final selection and justification of selection, scoring a minimum of 2

on each evaluated area of the given rubric.

Resources or Materials Needed:

- 15 complete case studies

- 15 rubrics (Appendix H)

- ChromeBooks (and chargers) - 1-to-1 computer access

- white board / chalk board (SmartBoard if preferred)

- TV or Projector

Time: 45 minutes

Step 1: Pre-Instructional Activities:

1. Students will enter fo find desks arranged in groups of 3 (or 5 stations set

for 3 students at each), a case study and grading rubrics on their desk.

2. The board will read:

1. Welcome to Day 8 of your internship! “What Are My Options, Doc?”

2. The objective for the lesson.

3. Bell Work:

1. Take out your Chromebook and open a new Google Doc that you

will share with the colleagues at your table.

2. Review the case study on your desk and identify the 2 treatment

options for this patient.

Step 2: Content Presentation:

1. Most medical problems are highly complex and ill-defined. There are so

many different systems, relationships and dependent variables that se-

lecting the appropriate treatment option for a patient can be difficult. At

times, it can be difficult to find a single treatment option, and other times,

there are many to choose from.

2. Previously, we have used creative approaches to finding and solving prob-

lems that have only a few possible solutions, or at the very least, have an

apparent “best choice” solution. Today, we are going to look at the other

side of the spectrum. We are going to look at a patient with a medical

problem that has at least 2 equally suitable options. Todays big question

is, “how do we choose a treatment plan when both treatment options will

benefit the patient?”.

3. You have looked over the case study and will need to identify 2 treatment

options that you will be investigating. With your team, you will each com-

pose (together in your shared Google Doc) an outline for each treatment

option. This will include why each of the treatment options are the best

for the patient, any potential drawbacks of both treatments and justifica-

tion based off of information found in the patient case study to support

the selection of both.

4. Now, I’m sure you are wondering why you have to defend both treatment

options rather than selecting only one. The reason for this is that your

team will be creating a video tomorrow that will present both cases and

justification for which treatment option will be the best choice for this pa-

tient.

5. Refer to the rubric for the details of the outline. All outlines will be turned

in via Google Classroom and each team member must contribute to both

of the outlines that will be turned in. It may be helpful to go on and desig-

nate who will present treatment option 1, who will present treatment op-

tion 2 and who will present the final treatment options selection and justi-

fication based off of information found in the patient case study.

Step 3: Learner Participation:

1. Students will spend the rest of the class period working with their team.

The teacher should be circulating for observation, small group

interaction/scaffolding, correcting misconceptions and asking probing

questions to help students interact with the lesson on a deeper level.

2. In the last 10 minutes of class, students need to finalize their outlines, in-

dicate who will be assuming each of the 3 roles for lesson 9 and turn it in

via Google Classroom. The rest of this time should be spent answering

any questions the students need answered to insure understanding of the

assignment and how to adequately be prepared. Students that struggle

with presentation skills can be encouraged to create a script for their part

in the presentation but need to be aware that they will loose points if they

have to read their script rather than using it for occasional reference.

Step 4: Assessment:

Formative assessment for this lesson will be in the form of teacher ob-

servation, student-teacher interaction and small group interaction. This is an

opportune time for the instructor to identify ability levels, misconceptions,

and assess the previously taught skills for this unit to ensure that students

have a solid foundation in the previous 7 skills. Pace of instruction and scaf-

folding may be adjusted as needed to meet all student needs.

Summative assessment will provided by the grading rubric found in Ap-

pendix H. This rubric will provide clarification for students and details about

expected performance on the outline. It will also help them prepare for les-

son 9’s presentation by ensuring that they have thoroughly investigated

each treatment options and have sound justification before making their

video presentation.

Step 5: Follow-Through Activities:

Students will prepare for their role in the video presentation outside of

class (homework). They should be encouraged to use the grading rubric as a

guide to ensure completeness of their argument or justification. Students

will need to come to class prepared to begin their video and will not be given

further class time to complete their preparation.

Students should be encouraged to be creative and make an engaging

video. This may include role playing, props, graphics, etc. that will bring their

video to life. The creativity should not overshadow the purpose of the video

but enhance the aesthetics and entertainment factor.

Lesson 8 Case Study and InformationemDocs Cases: Headache Management in the ED• NOV 20TH, 2017 BRIT LONG CATEGORIES:

Author: Brit Long, MD (@long_brit, EM Attending Physician, San An-tonio, TX) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attend-ing Physician, UTSW / Parkland Memorial Hospital)Welcome back to emDocs Cases! Today we have case-based discussion on a core EM topic, with a look at some controversy and cutting-edge treatments.

A 28-year-old female presents with right sided headache and one episode of vomiting, but no abdominal pain. The headache is not sudden in onset, but has rather worsened gradually over the last several hours. She denies fever, neck stiffness/pain, trauma, ingestion, vision changes/eye pain, and any other complaints. She has had several headaches in the past similar to the present headache. Her VS and exam are normal, including gait, cerebellar system, motor/sensory, reflexes, gait, and cranial nerves.

How are headaches classified?Headaches affect over 50% of patients annually, with close to 4% of ED visits for headache.1-3 Women are more commonly affected.4-6 In the ED, physi-cians must first evaluate for potentially life-threatening causes of headache, as well as treat patient symptoms.Primary headaches are not life-threatening, but they can cause significant morbidity. These headaches include tension, migraine, cluster, paroxysmal hemicranias, hemicrania continua, trigeminal neuralgia, and medication overuse.6-12Secondary headaches are dangerous and may result in death if not diag-nosed and treated. These include intracranial hemorrhage, sentinel bleed, meningitis, encephalitis, abscess, tumor, carotid/vertebrobasilar dissection, reversible cerebral vasoconstriction syndrome (RCVS), cerebral venous thrombosis, temporal arteritis, idiopathic intracranial hypertension, hyperten-sive encephalopathy, posterior reversible encephalopathy syndrome (PRES), acute hydrocephalus (e.g., colloid cyst obstructing third ventricle), pituitary apoplexy, acute angle closure glaucoma, and carbon monoxide poisoning.6-12What evaluation is necessary in the ED?The most important component of the ED evaluation is focused history and physical exam (including HEENT and neurologic systems). This evaluation comes down to looking closely for “red flags”.6-8 Patients with a benign headache should have no major change in headache pattern, no red flag on history and exam, and no high-risk comorbidity.6-8,10

What is a primary, or benign, headache?Most headaches managed in the ED are benign, with 90% of these headaches classified as tension, migraine, or cluster. These differ in symp-toms, but our job in the ED is to not diagnose the specific type of primary headache, but rather exclude a secondary dangerous headache.3,4,7-13Migraines have several criteria for diagnosis, shown in the table below. Sev-eral factors increase the likelihood of migraine headache, including nausea/vomiting, photophobia, and limitation in work/daily function due to headache (2 of 3 of these criteria possess sensitivity over 80%).3-5,12,13

What treatments are available, and which medications are effica-cious?Emergency physicians have another major role in the care of these patients by treating symptoms. This is one area where we can truly help patients. Treatment of nausea, vomiting, and pain should be a primary goal in ED care, no matter the headache etiology.6-12 Over twenty different types of medications are available, many with different routes (parenteral, intranasal, subcutaneous, and oral). Many of these medications are provided in the

“headache cocktail”, which varies based on the physician, institution, patient preferences, and other factors. The best medication should provide fast, sus-tained pain relief, while having little to no side effects. Unfortunately, there is no perfect medication, and over one third of patients managed in the ED for headache experience sustained pain relief.10,14 Medication complications include vascular problems, extrapyramidal effects, and gastrointestinal is-sues such as gastritis or hemorrhage. The American Headache Society re-leased updated recommendations in 2016 for headache treatment. As you can see, clinicians have a large number of options…What should you choose?Many studies have evaluated medication efficacy for benign headaches. The rest of this post will look at some of the more common medications used for headache treatment in the ED.1. Antidopaminergic agents – This is one of the best classes for symptom management, including headache pain and nausea relief.6-13 This class con-sists of phenothiazines and butyrophenones. Drowsiness is the most com-mon side effect, and abnormal movements such as dystonia and akathisia may occur as well (more common with faster infusion rates).6,9,10Chlorpromazine, prochlorperazine, and promethazine are phenothiazines. Chlorpromazine is provided in 0.1 mg/kg IV, with studies suggesting im-proved pain, photophobia, and phonophobia in migraines, with NNT of 2 for pain relief at one hour.16-21 Prochlorperazine is more commonly used in the U.S., with dosing 10 mg IV providing pain relief in up to 90% of patients.22-30  This medication has been compared to magnesium, valproic acid, suma-triptan, octreotide, and ketorolac, with literature suggesting superiority of prochlorperazine.22-30 Promethazine can be used in doses of 25 mg IM or IV (IV administration can produce soft tissue injury if the medication ex-travasates).5,31-33  Fewer studies have evaluated its use in the ED.Butyrophenones include droperidol and haloperidol. Droperidol possesses strong literature support as an analgesic and antiemetic in headaches, with doses ranging from 0.1-8.25 mg IM providing effective pain relief. It may be provided IV as well.6-13,34-36  However, it possesses an FDA Black Box warning for QTc prolongation. Haloperidol provides analgesia that is compa-rable or better to other previously discussed medications.9-11,38-40  When compared to placebo, haloperidol provides pain relief in 80% of patients. 39One of the most common medications used in a “headache cocktail” is meto-clopramide, an antidopaminergic and serotonin receptor antagonist, often administered 10 mg IV or IM.9-11,24,26,40-45  This medication has signifi-cant literature support, with one meta-analysis suggesting a NNT of 4 for pain reduction.43  Akathisia is a potential side effect, which can be reduced with slower rate of infusion.9-11,40-442. Triptans – These medications are serotonin receptor agonists (5HT1B/1D), primarily used in the outpatient setting.8-13,21,23,46-48 One of the more common agents is sumatriptan 2.5-6 mg given subcutaneously, with an NNT of 2.5 for pain relief when compared to placebo.9-13,47  It can also be

administered intranasally (10-20 mg) or PO (100 mg).10,11,46-48  Unfortu-nately, there are many potential side effects such as chest pain, shortness of breath, flushing, and worsening headache, with number needed to harm (NNH) of 4.47 This medication should not be used for patients with cardio-vascular disease, uncontrolled hypertension, or pregnancy.9-13,47  To re-duce the risk of overuse headache, patients should not use a triptan more than 2 days per week. Close to two thirds of patients may experience recur-rent headache.47 Triptans also demonstrate efficacy in cluster headaches, with sumatriptan 6 mg subcutaneously demonstrating pain relief in 75% of patients at 20 minutes and intranasal sumatriptan also beneficial.49-51 Zolmitriptan is given in doses of 5-10 mg.51,52  A maximum of two doses in 24 hours is recommended.3. NSAIDs – This class can be used for a variety of conditions, with evidence strongly supporting use in headaches. Ketorolac in doses 30 mg IV or 60 mg IM is one of the most commonly evaluated medications.6-13,53-55 IV and IM routes show up to 80% pain relief at 2 hours, with similar pain relief when compared to metoclopramide or chlorpromazine. 9-11,27,54 Naproxen 500-550 mg two times per day can reduce pain if used for patients with headache, but does not decrease headache recurrence.55 If taken daily, gas-tric protection is recommended, and extended use may cause chronic daily headaches.9-13,554. Acetaminophen – This medication is useful for headache therapy, with recent studies evaluating IV dosing.8-13,56,57 Studies have suggested equivalency to dexketoprofen 50 mg, with no adverse events. The medica-tion outperforms the triptan class at 60 minutes in terms of pain relief, though not at 30 or 120 minutes.56,57 More research is needed, but this class is promising.5. Steroids – Though early studies demonstrated analgesic benefits for acute treatment,58,59 more recent randomized studies do not suggest effi-cacy for acute pain treatment.60-64 However, steroids can reduce risk of headache recurrence in 24-72 hours, with NNT 9.9-13,65 Another meta-anal-ysis and systematic review suggest similar results.66,67 This must be bal-anced with potential risks of steroids, especially with older patients and dia-betics. The most common steroid utilized is dexamethasone, in doses of 8-16 mg. The most prevalent dose and route evaluated is dexamethasone 10 mg IV.9-136. Antihistamines – Diphenhydramine and promethazine are two medica-tions from this class. This is a common component of the ED “headache cocktail”, based on studies suggesting elevated serum histamine and IgE lev-els in migraine patients, and patients with migraine may have higher preva-lence of allergic rhinitis.68-72 Unfortunately, these agents do not possess strong literature support, with one study comparing metoclopramide versus metoclopramide + diphenhydramine suggesting no difference in pain, akathisia, or length of stay.68 This medication class may cause sedation, but likely do not assist in analgesia.9-13

7. Intravenous Fluids – Over 40% of ED headache patients are given IV flu-ids.4,5,9-13 Patients may have fluid loss from vomiting and decreased oral intake. However, concerning pain relief, a study evaluating IV fluids with metoclopramide versus metoclopramide alone found no difference in acute pain relief.73 If the patient appears dehydrated, IV fluids are helpful, but they otherwise likely do not assist in pain relief.Going beyond the standard “headache cocktail”…8. Oxygen – Supplemental oxygen is efficacious in cluster headaches and is recommended by headache guidelines.74,75 If cluster headache is sus-pected on clinical evaluation, oxygen should be given, though other headaches do not demonstrate a similar response to oxygen.6-13,74,75 In migraine or tension type headaches, oxygen is likely not helpful.9. Valproic Acid – Though most commonly used for seizures, this medica-tion has been used for headache management in doses of 300-1200 mg IV.9-13,54,76 Randomized controlled trials (RCTs) demonstrate varied efficacy for symptom improvement when compared to ketorolac, metoclopramide, and prochlorperazine.54,76-82 Contraindications include pregnancy, liver dis-ease, and metabolic disorders such as urea cycle defects.10. Propofol – Propofol demonstrates efficacy in analgesia for refractory headaches.9-13,83-85 Studies have evaluated varying doses of propofol. One study found propofol in 30-40 mg IV boluses (with 10-20 mg boluses ev-ery 3-5 minutes) had better pain relief and decreased adverse events when compared with sumatriptan. 85 Another study evaluated propofol 10 mg IV every 5-10 minutes up to 80 mg, finding this strategy was effective in anal-gesia.86 Propofol is useful in refractory pain relief, though close monitoring for hypotension and respiratory depression is recommended.11. Ketamine – Finally to the NMDA antagonist that is changing emergency medicine, first in procedural sedation and now analgesia.6,9-13,86-90 Anal-gesic doses of 0.1-0.3 mg/kg IV as slow push have found ability to decrease pain, though one study suggests feelings of fatigue and insobriety were more common with ketamine.89  Ketamine in 100 mL of NS with slower infusion over 15 minutes may reduce these feelings, versus faster infusion over 5 minutes.91 12. Magnesium – Severe asthma/COPD, preeclampsia/eclampsia, atrial fib-rillation…this medication possesses a variety of uses in the ED. For patients with headache, it can be given in doses of 1-2 g IV. However, RCT’s evaluat-ing magnesium are not high quality, and the literature suggests magnesium does not consistently provide analgesia for severe headaches.92-9513. Nerve Block – This includes several different blocks with an anesthetic, including the occipital nerve block and sphenopalatine ganglion block. The occipital nerve block has been studied in open label trials and observational cohorts, and studies suggest the block is effective in over 65% of patients.9-13,96Another option is the sphenopalatine ganglion block, which reduces parasympathetic outflow and pain.97-99  Academic Life in EM has a great post on this procedure with video. Several studies suggesting benefit against

placebo, though the studies are not well designed. Another study comparing bupivacaine versus saline placebo found no difference in pain relief at 15 minutes,99 though others suggest improved pain at 15 minutes, 30 minutes, and 24 hours.98,100 Intranasal lidocaine is helpful in patients with cluster headaches and should be used if this is suspected.101-10514. Opioids – You can’t really talk about analgesia without discussing opi-oids. These are used in over 50% of patients in the ED for headache.9-13 However, we have a significant number of alternative agents. Plus, several societies recommend against opioids for headaches, as these medications may cause headache progression, increase frequency of revisit, and de-crease efficacy of other headache treatments. 9-11,106-114 Opioids can also increase depression, anxiety and disability.116 If patients ask specifically for opioids, counseling on the risks of this treatment is recommended.So when it comes down to it, what medications should you provide?As discussed, you have many choices. Antidopaminergics in combination with an NSAID, acetaminophen, and dexamethasone will reduce pain and nausea. If ketorolac is chosen, recent literature suggests reduced dosing (10 or 15 mg) is as efficacious as 30 mg, with reduced risk of side effects.123 Triptans can be used, but only if there are no contraindications. If no re-sponse to first line agents, then nerve block, ketamine, or propofol can be used. Nerve block is useful for rapid pain relief.

 

Lesson 8: What Are My Options, Doc? - Outline Rubric

Objective: Given complete case study with at least 2 viable treatment options, the students will us problem solving sub-skills to create an online for an argument they will use to defend both treatment options, scoring a minimum of 2 on the given rubric.

Lesson 8: What Are My Options, Doc? - Outline Rubric

Area of Evaluation 1. Not Evident/Approaching Competence

1. Benefits of Treatment 1

Group outline included 2 or fewer relevant points detailing the benefits of treatment option 1 based on information found in the case study.

2. Disadvantages of Treatment 1

Group outline included 2 or fewer relevant points detailing the disadvantages of treat-ment options 1 based on information found in the case study.

3. Evaluation of Benefit/Risk Analysis of Treatment 1

Group outline included 2 or fewer relevant points for the benefit-to-risk analysis of treatment option 1 and/or failed to have justification in the form of details found in the case study.

4. Benefits of Treatment 2

Group outline included 2 or fewer relevant points detailing the benefits of treatment option 2 based on information found in the case study.

5. Disadvantages of Treatment 2

Group outline included 2 or fewer relevant points detailing disadvantages for treatment option 2 based on information found in the case study.

6. Evaluation fo Benefit/Risk Analysis of Treatment 2

Group outline included 2 or fewer relevant points for the benefit-to-risk analysis of treatment option 2 and/or failed to have justification in the form of details found in the case study.

7. Recommended Treatment

Group outline did not include a recommended treatment option and/or did not use the benefit-to-risk analysis to inform their decision and/or did not include justification in the form of information found in the case study.

8. Group ParticipationGroup outline included productive and positive contributions from 1-2 group members

9. Plan of Presentation

Group outline did not include a plan of presentation and/or did not provide sufficient details (member presentation role and sequence of presentation) to be prepared for the video recording in lesson 9.