Emergency
Vol. 38, No. 11
Medicine News
THE MOST TRUSTED NEWS SOURCE IN EMERGENCY MEDICINE www.EM-News.com
Morphine Might
Maximize
Mortality in APE
BY DAN RUNDE, MD
N o patient looked sicker or
scared me more when I was a
new resident than the 6 a.m. acute
pulmonary edema patient who
rolled in gasping desperately for
air. Now that I’m older, better at
crushing my fear and anxiety into a
teeny-tiny ball to be released later at
a wildly inappropriate time, and have
seen the wonders that a little BiPAP
and a lot of intravenous nitroglycerin
can do, I’m less likely to hit the panic
button when I see a patient with
APE pop up on the board.
Unfortunately, that fear is now
sometimes replaced by rage, and
it’s a rage caused by a consultant
or EM trainee ordering intravenous
morphine as part of the treatment
plan. I know that EM providers are
busy people, so if you’re reading
this on shift, I’ll save you the
trouble of tackling the rest of the
article: Do not give morphine to
Continued on page 31
Periodicals
November 2016
LIPPINCOTT
WILLIAMS & WILKINS
Beating the
Dunning-Kruger
Effect at Its
Own Game
BY GINA SHAW
S ocial psychologist David Dunning,
PhD, recently said he had fallen
victim — for years — to the cognitive
bias he had helped name. That famous
1999 article in the Journal of Personality
and Social Psychology revealed that the
Dunning-Kruger effect occurs when in-
Patronauta/Thinkstock.com
dividuals assume that their competency
in a given area is significantly higher
than it is.
Continued on page 28
A Game Changer and a Lifesaver for Sepsis
BY CHRISTINE BUTTS, MD and starting the appropriate
­antibiotic is critical in limiting
U ltrasound in diagnosing sepsis
up until this point has primar-
ily focused on volume resuscitation.
mortality.
The source diagnosis may be
easily identified in patients with
Lippincott Williams & Wilkins, 2016.
Identifying those who are volume de- clear symptoms (cough, dysuria)
pleted and those who may respond to and findings of systemic inflam-
fluids has been the focus of a number matory response syndrome
of studies. A missing factor in these ­(tachycardia, tachypnea, fever,
evaluations is getting to the root of alterations in white blood cell
the problem: identifying the source of count). The diagnosis may be
sepsis. This is key as source control, Continued on page 30
Who Said the Opioid Crisis
Couldn’t Get Any Worse?
BY LEON GUSSOW, MD
T
SanchaiRat/Shutterstock.com
he opioid crisis, already the worst man-made
epidemic in history, suddenly became more
dramatically alarming.
Canadian authorities in Vancouver announced in
August that they had seized one kilogram of the
synthetic opioid carfentanil. The stash had been
Continued on page 29

Morphine
Continued from page 1
patients with acute pulmonary
edema.
I should start by saying that in
this discussion we’re really talking
about patients presenting with
acute decompensated heart failure
(ADHF), and that we don’t have
any good randomized control trials
on this. What evidence there is,
however, is startling enough that it
should give even the most cavalier
cardiologist and egotistical emer-
gency physician cause for concern.
The most compelling and cer-
tainly the most cited article on
morphine for APE was performed by
W. Frank Peacock IV, MD. (Emerg
Med J 2008;25[4]:205.) Before look-
ing at the paper, we need to ac-
knowledge how awesome his name
is. This was a retrospective analysis
of the Acute Decompensated Heart
Failure National Registry (ADHERE)
that compared the records of 20,782
hospitalizations for APE where the
patient received IV morphine with
126,580 hospitalizations where the
patient was not given morphine. The
quick summary is that the patients
who received IV morphine did worse
in essentially every way, but I’ll sum-
marize the high points here:
n Need for intubation: 15.4 per-
cent in the morphine group vs. 2.8
percent in the no-morphine group
(NNH=8).
Twelve dogs and 25 patients formed
the basis for using morphine in APE
n Need for ICU admission: 38.7
percent in the morphine group vs.
14.4 percent in the no-morphine
group (NNH=5).
n Mortality: 13.0 percent in the
morphine group vs. 2.4 percent in
the no-morphine group (NNH=10).
Worse Outcomes
It’s true that the patients who re-
ceived morphine did have some
baseline differences. The authors
noted “a higher prevalence of rest
dyspnoea, congestion on chest ra-
diography, rales, and raised troponin
occurred in the morphine group.”
They performed risk adjustments for
pretty much every conceivable un-
derlying risk factor or patient char-
acteristic to account for this. It
didn’t matter: Morphine was associ-
ated with worse outcomes and in-
myths in em: know better, do better
creased mortality (i.e., OR 4.84
(95% CI 4.52 to 5.18), p<0.001) in
every mode of comparison.
Judd Hollander, MD, who is no
methodological slouch, was the
second author on this paper, and I’m
going to name-drop him by way of
vouching for the statistical analyses
performed.
I would be remiss if I didn’t
stress that we can only draw limited
conclusions for this type of retro-
spective study, noting a strong as-
sociation between IV morphine
­administration in patients with APE
and poor outcomes. This is different
from claiming that morphine is
what’s causing the poor outcomes.
That said, the strength of the associ-
ation here is compelling, and there
is a paucity of evidence demonstrat-
ing any benefit for using morphine
for APE patients.
Where did this whole morphine
for APE originate? I remember
learning that it worked by reducing
preload, to a lesser extent after-
load, and that it decreased heart
rate and lessened oxygen hunger.
The evidence for this? Please let
me refer you to a wonderful review
article titled, appropriately enough,
“Morphine in the Treatment of
Acute Pulmonary Oedema — Why?”
(Int J Cardiol 2016;202:870.)
The authors wrote, “The back-
ground of this belief is three trials
from 1966 to 1976, where the groups
consisted of 12 dogs, 12 patients
with myocardial infarction (where
What did they find? Nitro
seemed to be beneficial, and fur-
osemide and morphine “may not
add anything to its efficacy, and
may be potentially deleterious in
some of these patients.” On the
downside, the study only en-
rolled 57 patients, 23 of which
(40%) turned out not to have
APE but rather things like pneu-
monia and COPD. We hold Dr.
Hoffman in great regard, but
this was not necessarily a game-
changing paper.
Lippincott Williams & Wilkins, 2003.
Not to be outdone, fellow EM
luminary, Alfred Sacchetti, MD, and
colleagues undertook a chart re-
view of 181 patients with APE, look-
ing at associations between what
kind of medications they received
and how often they were intubated
and admitted to the ICU. (Am J
nobody received morphine as the Emerg Med 1999;17[6]:571.) And
sole drug), and 13 patients with mild the results? IV morphine was as-
pulmonary oedema, respectively. ... sociated with increased odds of
[I]n 1994, a trial with vessels from being intubated (OR 5.04; p=0.001)
dogs in vitro showed that morphine and increased ICU admissions
The bottom line: Do not give morphine to
patients with acute pulmonary edema
had a relaxing effect on the smooth (OR 3.08; p=0.002). Again, this
muscles in both veins and arteries.” was a chart review of a relatively
We basically have a cohort of two heterogeneous group, and the as-
dozen dogs, a dozen people with MI, sociation between IV morphine
and 13 patients with mild pulmonary and worse outcomes was pretty
edema forming the basis for using straightforward.
morphine in patients with APE. If you’ve stuck with me this far,
When balanced against the striking the take-home point should be
negative association found in the pretty clear, but just to summarize
ADHERE trial, a study showing some one more time: Do not give
canine vasodilation is a weak basis morphine to patients with acute
for putting our patients at risk. pulmonary edema. Perhaps
someday a study will give us cause
Older Studies to revisit this issue, but until then
What about older studies per- I’ll hold the morphine rather than
formed by well-known emergency holding my breath. EMN
physicians whom I love and trust,
you ask? So glad you did. None Share this article on Twitter
other than the esteemed Jerry and Facebook.
Hoffman, MD, published a study Access the links in EMN by
examining the efficacy of various reading this on our website or in
pharmacological treatment regi- our free iPad app, both available
mens given by EMS to patients at www.EM-News.com.
Comments? Write to us at
with presumed pulmonary edema.
emn@lww.com.
(Chest 1987;92[4]:586.)
Dr. Runde is the assistant residency director and an assistant
professor of emergency medicine at the University of Iowa
Hospitals and Clinics, where he serves as co-director for the
associate fellowship in medical education. He creates content
for and is a member of the editorial board for www.TheNNT.
com, and is a content contributor for www.MDCalc.com. Fol-
low him on Twitter @Runde_MC, and read his past articles at
http://bit.ly/EMN-MythsinEM.
Emergency Medicine News | November 2016 31