When I saw this article in Annals , I was sure that I have seen it before, but could not believe that 2 studies with almost same methods, same number of patients, and same dose of medication. Read More Low Dose Ketamine for Analgesia

General EM PGY1 PGY2 PGY3 PGY4

Well, I just sent an article that how important is the role of vital signs during pre-hospital or in ED assessment. Annals of EM published an article: Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. In a prospective observational study, authors  observed 1,163

Read More Importance of Vital Signs during Handoff

General EM PGY1 PGY2 PGY3 PGY4 Uncategorized

PGY1 PGY2 PGY3 PGY4 Sepsis

Infectious Disease PGY1 PGY2 PGY3 PGY4

Clearance of suspected c-spine injuries specifically in AMS is one of the challenging topics in trauma. How do you clear C-spine in obtunded  patient? well, as you know there are 2 methods:  MRI or/and Flex-ex xray.There is a new study published in Annals of Internal Medicine in March:
Cervical Spine Clearance in Obtunded Patients After Blunt Traumatic Injury: A Systematic Review

Read More Clearance of suspected c-spine injuries in obtunded patient

PGY1 PGY2 PGY3 PGY4 Trauma

Cardiology PGY1 PGY2 PGY3 PGY4

I highly recommend you to take a look at this article published in American Heart Journal last week(Feb, 2015). The authors identified 11 class 1A(means the best evidence) in  STEMI or UA/NSTEMI and they followed them form clinical trial publication til meaningful application into clinical practice.  It took 16 years for clinician to apply those evidence into practice.

Read More Evidence Base Medicine is a challenge in clinical practice!

Cardiology PGY1 PGY2 PGY3 PGY4

Pediatrics PGY1 PGY2 PGY3 PGY4 Trauma

Neurology PGY1 PGY2 PGY3 PGY4

Anaphylaxis PGY1 PGY2 PGY3 PGY4

Another study from AJR in Jan 2015 focused on dizziness/syncope. Due to difficulty to define definition of dizziness among patients, they used 3 terms of Dizziness, Syncope, and Read More Head CT for Syncope/Dizziness

Cardiology PGY1 PGY2 PGY3 PGY4

I used Low Dose Ketamine for Pain relief in ED, and I had a very good experience with it, but new study in AJEM Feb, 6, showed that compare with morphine ,LD Ketmaine Read More Ketamine for Pain Relief

General EM PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Trauma

Cardiology PGY1 PGY2 PGY3 PGY4

OXYGEN! Please put  patient on NC 2 -4. This is one of our critical action in mock oral board questions, but is it really a critical action, how much oxygen do we need for a pt w/o hypoxemia? Read More Oxygen, Good or bad!

Cardiac arrest PGY1 PGY2 PGY3 PGY4

It is interesting that you teach a concept and try to back it up with some literature, but sometimes you do not have a simple tools to show it. Canadian Journal of Anesthesia published an article Laryngoscope manipulation by experienced versus novice laryngoscopists in December 2014. This is exactly what I’m talking about! how to grab a laryngoscope and how to manipulate it. Read More How to handle a Laryngoscope!

PGY1 PGY2 PGY3 PGY4

It is good to tell residents something and back it up with some EVIDENCE!!! such as your Mentor is not someone to tell you something that You want to hear!…

Read More Some Advise for Residents!

General EM PGY1 PGY2 PGY3 PGY4

This is a very routine practice in ED, “I’ll be more comfortable to give one dose of Abx and then send him/her home” I did not know where this quote came from. I searched Pubmed and found this article: Antibiotic use in the emergency department. IV: Single-dose therapy and parenteral-loading dose therapy. J Emerg Medicine in 1996!!! Read More Single Dose Antibiotic before ED Discharge!

Infectious Disease PGY1 PGY2 PGY3 PGY4

We discussed 2 studies in our class specific session on impact of EPi on out of hospital cardiac arrest. J Am Coll Cardiol published another study  this month and challenged again use of Epi in OHCA. 1,556 patients from 2000 to 2012, using EPi with different doses, and the conclusion is  pre-hospital use of epinephrine was consistently associated with a lower chance of survival.

Read More Epinephrine in OHCA!

Cardiac arrest Cardiology PGY1 PGY2 PGY3 PGY4

In my series of EBM, I was talking on our grand rounds regarding restrictive vs liberal strategies for blood transfusion! I have already posted the evidence for it. But NEJM published a study in septic shock patient that will really change practice: Read More Thershold for Blood Transfusion

Hematology PGY1 PGY2 PGY3 PGY4

Very nice mnemonic for Cavity lesion DDx in cxray: Cavity, C: Cancer or Mets, A: autoimmune; granulomas from, V: vascular (both bland and septic pulmonary embolus), I: infection(TB, fungall), T: trama…

Read More Cavity Lesion

PGY1 PGY2 PGY3 PGY4 Pulmonary

We are very familiar with the term of Angioedema. Mostly comes from ACE-In but has a large ddx from NSAIDS to hereditary to idiopathic. There is an article in Academic EM that is discussing the treatment options for Angioedema. Read More Angioedema to Treat or Not to Treat

Anaphylaxis PGY1 PGY2 PGY3 PGY4

I was giving lecture regarding this topic and some challenging concepts in SCC including  IV therapy, oxygen therapy, blood transfusion, and always could not give a comprehensive reference to back myself up. Read More Sickle Cell Disease

Hematology PGY1 PGY2 PGY3 PGY4

Morphine can affect functionality of Clopidogrel. There is an article in JACC, March 2014, that showed “Morphine delays clopidogrel absorption, decreases plasma levels of clopidogrel active metabolite, and retards and diminishes its effects, Read More Morphine delays Clopidogrel effects!

Cardiology PGY1 PGY2 PGY3 PGY4

Alpha blocker (Tamsulosin , Flomax) originally is used for medical treatment of BPH. There are growing concerns that alpha blocker can be used in treatment of ureteral stone due to same affect on bladder and prostate, relaxation of muscle fiber. The recent Cochrane Read More Alpha Blocker as a treatment for Ureteral Stone!

PGY1 PGY2 PGY3 PGY4 Urology

Medical Principles and Practice published an article that uses a structured teaching tools to summarized 5 Hs and 5 Ts in PEA cardiac arrest, Lets start with 5 Hs(Hyper and Hypo K, Hypoxia, Hydrogen, Hypovolemia and Hypothermia) and 5 Ts( Tension PTX, Tamponade, Trauma, Toxins, Thrombosis), a very routine practice in ACLS guideline, Read More PEA Cardiac Arrest and Structured Teaching tool

Cardiac arrest PGY1 PGY2 PGY3 PGY4

I had several discussions in ED regarding blood transfusion in anemic patients. My argument is that if patient does not have any acute symptoms (SOB, feeling faint, tachycardia, Cardiac ischemia, …), there is no need to emergently Read More Blood Transfusion in 2014

Hematology PGY1 PGY2 PGY3 PGY4

We are usually observing patients in emergency department in length due to biphasic reaction. There are 2 articles published during last 6 months and they emphasized regarding of  how common is biphasic reaction and mortality of this reaction! Read More Biphasic allergic reaction

Anaphylaxis PGY1 PGY2 PGY3 PGY4 Uncategorized

Cardiology PGY1 PGY2 PGY3 PGY4

NEJM published a study regarding appropriate MAP among patients with septic shock. Originally MAP of 65 was a target but the Surviving Sepsis Campaign guideline was recommending patients with HTN, may have benefit for higher Read More Still MAP of 65 Works!

PGY1 PGY2 PGY3 PGY4 Sepsis

NEJM published The ProCESS study. Basically, this study aimed to challenge EGDT by Manny Rivers in 2001, a very prestigious and novel approach to septic patient in ED. The EGDT was ED based approach. although some of the components were very difficult to acheived in ED such as Scvo2. The EGDT study showed 16% reduction in mortality, but Rivers faced lots of questions including feasibility of this approach in ED, and necessity of blood Read More EGDT or ProCESS , That is the question!

Infectious Disease PGY1 PGY2 PGY3 PGY4

General EM PGY1 PGY2 PGY3 PGY4

This is a challenging question that always comes up in patients with food bolus. What evidence do we have to recommend Glucagon in this situation? is this another version of Kayexalate in case of hyperkalemia? ;) Read More Glucagon and Food bolus

GI PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Trauma

Cardiology PGY1 PGY2 PGY3 PGY4

As much as I read the literature, I really don’t know the BP is my friend or enemy. If you look at the Stroke guideline published in 2013, their recommendation for lowering  BP is”not to lower the blood pressure during the initial 24 hours of acute ischemic stroke unless the blood pressure is >220/120 mm Hg” but there is no reference to Read More Blood Pressure Reduction and Acute Ischemic Stroke

Neurology PGY1 PGY2 PGY3 PGY4

Neurology PGY1 PGY2 PGY3 PGY4

Discharge Against Medical Advice, Pitfalls and Troubleshooting. There is a very interesting article from JAMA in Nov. 2013, explaining of misconception and how misleading is information regarding discharge patient with AMA. I always discuss with residents that signing an AMA form does not mean anything unless you document the patient’s condition and mental status and details of your discussion in medical record. Read More Discharge Against Medical Advice, Pitfalls and Ttroubleshooting

General EM PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Pulmonary

General EM PGY1 PGY2 PGY3 PGY4

Orthopedics PGY1 PGY2 PGY3 PGY4

Orthopedics PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Pulmonary

Pain management in ED is a challenging topic. Teaching residents to start with NSAIDS vs Narcotics and Ibuprofen- Toradol vs Morphine- Dilaudid , always could be a place for discussion/argument. Read More Dilaudid (Hydromorphone), How much?

General EM PGY1 PGY2 PGY3 PGY4

I was working on LP study that we did, and found this article from JAMA, very informative. http://jama.jamanetwork.com/article.aspx?articleid=203808  

Read More Lumbar Puncture

Neurology PGY1 PGY2 PGY3 PGY4

Ultrasound

Neurology

Cardiology

MMWR in latest Grand round section discussed the options for gonorrhea treatment and their recommendation in case of  cephalosporin allergy,

Read More PCN resistant Gonorrhea

Infectious Disease PGY1 PGY2 PGY3 PGY4

and the question is:

Does limiting oral contrast decrease emergency department length of stay? we know the answer is YES, but this is something that we can share with our surgical consultants and as well Radiology colleagues

Read More Oral Contrast and LOS

PGY1 PGY2 PGY3 PGY4 Radiology

There is a new clinical Policy that Published in Feb, Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure. There was always a big ? regarding triage and disposition of these patients. There is no great data even on this clinical policy but at least we have some references for that. They answered to following questions:
Read More ACEP Clinical Policy: Asymptomatic HTN in ED

Cardiology

There are different approaches to Migraine HA, Narcotics, Triptans, NSAIDS, Steroids, … but my approach is combination of Metoclopramide and Diphenhydramine.

Headache The Journal of Head and Face Pain” Published a Systematic Review regarding Toradol and Migraine headache in Jan, and the conclusion is: Read More Ketorolac in the Treatment of Acute Migraine: A Systematic Review

Neurology PGY1 PGY2 PGY3 PGY4

This is the last update in 2012, but I am happy to end this year with one of the most challenging topics in medicine. The article is from J Am Coll Cardiol in Dec. You can find the Full text link here
1. Remeber: Troponin elevation imparts a worse prognosis, irrespective of the underlying etiology. Read More Challenges regarding Troponin

Cardiology PGY1 PGY2 PGY3 PGY4

Am J Respir Crit Care Med published a Practice Recommendations in the Diagnosis, Management and Prevention of Carbon Monoxide Poisoning in Oct 2012. We are almost there to see CO poisoning again, Just some points for quick look: Read More CO Poisoning, New pracice guideline

PGY1 PGY2 PGY3 PGY4 Toxicology

JACC in 2001 published an article that nicely explained the necessity of interpreting lead aVR in clinical setting. There are 3 categorizes that we should consider in this regard:1. acute…

Read More aVR: The most Ignored Lead

Cardiology PGY1 PGY2 PGY3 PGY4

 

What does typical chest pain mean? Traditionally, we thought that midsternal chest pain with radiation to left arm and increased with exertion, we just had another discussion on this topic on our grand round and all the studies and even Read More Typical Vs Atypical Chest pain

Cardiology PGY1 PGY2 PGY3 PGY4

That is the question: contrast CT or non contrast CT?   it is very difficult sometimes to answer, but for some facts such as r/o of appy, divericulitis and other pathologies, why…

Read More CONTRAST CT or NON CON CT?

PGY1 PGY2 PGY3 PGY4 Radiology

TIA is a huge dilemma in ED. It could be challenging from definition to workup to disposition, but recent article in clinics of north America, reviewed the pitfalls in diagnosis and disposition of patients with TIA. TIA is important because there is a chance of Stroke within 48 hours (5%). Read More Transient Ischemic Attack

Neurology PGY1 PGY2 PGY3 PGY4

What is your favorite hypertension numbers to treat in ED? there are a lots of controversies regarding the exact number to start treatment in ED but recent Cochrane review on mild HTN suggest that antihypertensive agents used in the treatment of adults with hypertension stage I (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) Read More Hypertension treatment

Cardiology PGY1 PGY2 PGY3 PGY4

Cardiac arrest PGY3 PGY4

Pediatrics PGY1 PGY2 PGY3 PGY4

We usually believe that pt with sickle cell trait is not as important as SCD(HbSS). In sickle cell trait, RBC has normal life span (120 vs 20) and no vaso-oclusive crisis. But article in the American Journal of Medicine, discussed a series of serious complication that can affect this type of patient ranging from hematuria, renal papillary necrosis, Read More Complications Associated with Sickle Cell Trait

Hematology PGY3 PGY4

Annals of Emergency Medicine published an article which it provided a formula to determine if we can differentiate between STEMI vs Early Repolarization. I really do not know in an acute setting I am able to sit down and calculate this but sometimes in terms of training it could be fun to do this practice!!! Read More EKG differentiation of early Repol vs STEMI

Cardiology PGY3 PGY4

I read this article long time ago but I had a discussion with one of my resident and to give her reference I would like to have it here. Basically…

Read More SYNCOPE vs Near SYNCOPE

Cardiology PGY1 PGY2 PGY3 PGY4

Very detail and informative article regarding Low Back Pain. I believe this article should be read by patients and physicians, and physicians can summarize this for their patients. This is…

Read More Low Back Pain

PGY1 PGY2 PGY3 PGY4

Cardiology PGY3 PGY4

Cardiology PGY1 PGY2 PGY3 PGY4

Diabetes PGY1 PGY2 PGY3 PGY4

Diabetes PGY1 PGY2 PGY3 PGY4

Cardiac arrest PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Trauma

Pediatrics PGY1 PGY2 PGY3 PGY4

Anaphylaxis PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Seizure

PGY1 PGY2 VTE

PGY1 PGY2 PGY3 PGY4 Pulmonary VTE

Cardiology Ultrasound

Diabetes PGY1 PGY2 PGY3 PGY4

This is a link to acep news for a presentation in American Epilepsy Society, 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study had PE http://www.acepnews.com/single-view/0addee7cac26f722aa1b28c431b5718f.html?tx_ttnews[tt_news]=945  …

Read More Seizure? Look for PE!!!

VTE

PGY1 PGY2 PGY3 PGY4 Sepsis

Cardiology PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Trauma

Infectious Disease Pediatrics PGY1 PGY2 PGY3 PGY4

Multimedia PGY2 PGY3 PGY4 VTE

General EM PGY3 PGY4

There are lots of questions raised recently regarding activation of cath. lab  in the setting of new LBBB or presumed new LBBB. It is really challenging when you have a patient with chest pain and there is no old EKG to compare findings of LBBB. Read More New LBBB and STEMI

Cardiology

Diabetes PGY1 PGY2 PGY3

Infectious Disease PGY1 PGY2 PGY3 PGY4

Pediatrics PGY1 PGY2

Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis?
There is a new study in Peds Emergency care which it describes a retrospective study among infants 1 month to 3 months old Read More Lumbar Puncture in febrile infant

Pediatrics PGY1 PGY2

Ultrasound

I had a patient with Carbon Monoxide poisoning. Patient had mental status changes and was unresponsive.We transferred patient to a hyperbaric center and this is the review that I did with my resident and student for Carbon Monoxide poisoning, mainly from Tintinalli’s: Read More CO Poisoning

PGY1 PGY2 PGY3 PGY4 Toxicology

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The goal of study was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Read More Children at very low risk of TBI per PEACRN

Pediatrics PGY3 PGY4 Uncategorized

Pediatrics PGY1 PGY2 PGY3 PGY4

Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?
another study on VBG vs ABG, I am sure in ED we almost agreed that a lot of ABG could be replaced by VBG but still among our consultant, this is not as clear as for us. this study Read More Are arterial and venous samples clinically equivalent….

Diabetes PGY1 PGY2 PGY3 PGY4

Cardiac arrest PGY3 PGY4

How do we measure the fluid status in a patient with shock? This usually measures with CVP or Ultrasound.  CVP measurement is possible when we have a  central line(subclavian or intra-jugular). Ultrasound brought a quick assessment of volume status or fluid Read More Volume Status in Septic Shock

PGY3 PGY4 Sepsis

Audio PGY1 PGY2 PGY3 PGY4

We all know that VBG can be replaced with ABG for a lot of reasons, but our consulatants are still asking for ABG in DKA, COPD, Asthma and etc. I will post some data that show VBG is as good as ABG unless you have a patient under vent. 
Diagnostic Accuracy of Venous Blood Gas Electrolytes for Identifying Diabetic Ketoacidosis in the Emergency Department.

Read More Diagnostic Accuracy of VBG in DKA

Diabetes PGY1 PGY2 PGY3 PGY4