When and how to image a suspected broken rib

Cleveland Clinic Journal of Medicine has a nice review on Rib Fracture and an algorithm to approach rib fracture. Read More …

Prophylactic Antibiotics for Anterior Nasal Packing in Epistaxis

Are Prophylactic Antibiotics Necessary for Anterior Nasal Packing in Epistaxis? There are some discussion regarding toxic shock syndrome and infections(otitis media, sinusitis) Read More …

ACEP Clinical Policy on Nontraumatic Aortic Dissection

In adult patients with suspected acute nontraumatic thoracic aortic dissection, is a negative serum D-dimer sufficient to identify a group of patients at very low risk for the diagnosis Read More …

Oxygen, Good or bad!

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 …

How to handle a Laryngoscope!

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 …

Some Advise for Residents!

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! but here some tips that can help you through your career:

advice for physicians in training: 40 Tips From 40 Docs

Single Dose Antibiotic before ED Discharge!

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 …

Epinephrine in OHCA!

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 …

Thershold for Blood Transfusion

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 …

Cavity Lesion

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 (pneumatocoeles), Y: youth (congenital pulmonary airways malformation) Reference

 

Angioedema to Treat or Not to Treat

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 …

Sickle Cell Disease

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 …

Morphine delays Clopidogrel effects!

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 …

Alpha Blocker as a treatment for Ureteral Stone!

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 …

PEA Cardiac Arrest and Structured Teaching tool

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 …

Blood Transfusion in 2014

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 …

Biphasic allergic reaction

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 …

Cardiac Risk factors, How important are they?

This is an old study by Annals of EM, The Role of Cardiac Risk Factor Burden in Diagnosing Acute Coronary Syndromes in the Emergency Department Setting, Feb 2007. Of 10,806 eligible patients, 871 (8.1%) had acute Read More …

Still MAP of 65 Works!

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 …

EGDT or ProCESS , That is the question!

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 …

ACEP Practice Guideline on Procedural Sedation

ACEP published Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department in Feb 2014. as usual critical questions and very useful answers. Let’s review them:

Read More …

Glucagon and Food bolus

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 …

INR overestimates coagulopathy in stable trauma and surgical patients

From OHSU, Portland, Oregon study came out in Journal of Trauma and Acute Care Surgery in Dec 2013.  The main idea was that INR should not guide to transfuse FFP in stable trauma patient. Read More …

JNC 8 is Out! New definnition of Hypertension!

After long wait! for JNC 8, it came online on Dec18, 2013. It was a long journey between JNC 7 and 8, it took 10 years! and now it is not endorsed by NHLBI(National Heart, Lung, Blood Institute). Read More …

Blood Pressure Reduction and Acute Ischemic Stroke

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 …

Headache and Common Questions

American Headache Society (AHS) published in Headache Journal list of 5 things physicians and patients should question in Nov 2013. This is a quick review and you can find full text here. Read More …

Discharge Against Medical Advice, Pitfalls and Ttroubleshooting

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 …

Bronchitis; Antibiotics or No Antibiotics, That is the question

Dilemma:  cough, smoker, discoloured sputum,  diagnosis: Bronchitis, now: Abx or no Abx

BMJ, Oct 2013:

Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial

Read More …

What is the optimal dose of Ketorolac as pain medication?

What evidence does exist regarding dosage of Ketolorac? Our practice is usually 60 mg IM and 30 mg IV, but interesting review by Medscape showed may be this is not a right dose. Read More …

Worsening Trends in the Management and Treatment of Back Pain

JAMA published an article emphasizing our EM textbooks highlights regarding the simple treatment of MSK back pain are NSAIDS and Acetaminophen and then muscle relaxant.  Read More …

Shoulder Dislocation and complications

Epmonthly had a very nice review with a mini board review perspective, regarding common complications of shoulder dislocation and reduction. Read More …

Short-term vs conventional glucocorticoid therapy in acute exacerbations of COPD

We are practicing short term of Steroid in management of asthma and COPD in ED, But this is very nice to hear from our colleagues to prove our practice. JAMA, in June 2013 published an article with concept of short term prednisone for 5 days is not inferior to Read More …

Dilaudid (Hydromorphone), How much?

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 …

Lumbar Puncture

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

 

Rate of and factors affecting sonographic visualization of the appendix in asymptomatic children

This is really disappointing to me when I see , in 55 % asymptomatic children, it took 15 min for pediatric sonographer to visualize entire appendix. They also could see some parts of appendix Read More …

Subarachnoid Hemorrhage Dillema, LP or Not To LP

Still a dilemma, Patient with thunderclap headache, sudden Onset, “worse headache in Life” and Ct scan and then CTA, MRA, LP??? still the classic answer works: CT non contrast and then LP, there are articles to decrease threshold in time sensitive period up to six hours, but still needs to have classic approach, CT. LP.

 

Time-dependent test characteristics of head computed tomography in patients suspected of nontraumatic subarachnoid hemorrhage.

 

Mortality of Patients With Atrial Fibrillation and an Alternative Primary Diagnosis

Acad Emerg Med, Feb 2013 published a Canadian retrospective cohort study reviewed patients with ECG, presented to ED with atrial fibrillation. The Outcome measure was mortality in short and long term (30 , 90 , 365 days) among patients with atrial fibrillation who had different primary ED diagnosis for their visits. Read More …

PCN resistant Gonorrhea

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

Read More …

Oral Contrast and LOS

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 …

ACEP Clinical Policy: Asymptomatic HTN in ED

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 …

Ketorolac in the Treatment of Acute Migraine: A Systematic Review

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 …

Challenges regarding Troponin

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 …

CO Poisoning, New pracice guideline

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 …

aVR: The most Ignored Lead

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 coronary syndromes, 2. acute PE, 3. arrhythmia. I strongly recommend you to take a look to the following link

JACC article

Typical Vs Atypical Chest pain

 

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 …

CONTRAST CT or NON CON CT?

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 do we need  Contrast CT? as an emergency physician, it is a matter of 2-4 hours of delayed disposition and increased LOS, more cost, more complications (Allergic reaction , Renal failure,..). I found this article very useful at least for acute appendicits, hope more come from our radiology colleagues

Link to Article

Transient Ischemic Attack

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 …

Hypertension treatment

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 …

Cardiac Arrest Survival Is Rare without Prehospital Return of Spontaneous Circulation

Wow. This is the third one, after 2 articles that showed Epi in prehospital really does not decrease mortality , now this retrospective study presenteddata that none of patients with asystole and no Read More …

Early Administration of Systemic Corticosteroids in Children With Asthma Exacerbation

July 2012: Annals of Emergency Medicine:

Early Administration of Systemic Corticosteroids Reduces Read More …

Complications Associated with Sickle Cell Trait

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 …

EKG differentiation of early Repol vs STEMI

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 …

SYNCOPE vs Near SYNCOPE

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 this study showed that Syncope and Near syncope has same critical interventions or adverse outcomes. This term should be taking care as we care about syncope.

Link To article

Low Back Pain

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 not new but still covers EBM by NEJM.

Link to article

New Concepts in the Assessment of Syncope

There is a State-of-the-Art Paper in the latest edition of Journal of the American College of Cardiology, May 2012.The title of article is New Concepts in the Assessment of Syncope. The authors perspective was based on the presence of a syncope specialist (“the right physician”), adequate equipment including online prompting tools and logistics (“the right place”), and optimal organization (“the right time”), as exemplified in a syncope facility, have been shown to improve at least short-term outcomes.

Link to article

What is the role of Morphine in Flash Pulmonary Edema?

We always taught that Morphine can decrease preload and can help with anxiety and  pain in acute flash pulmonary edema. But evidence does not support this Claim.  Read More …

Standards of Medical Care in Diabetes: 2012

This is the Standards of Medical Care in Diabetes: 2012 by American Diabetes Association (ADA). There are a lots of useful information can help for new criteria for diabetes and so on.

Link to PDF

 

 

 

Comparison of arterial blood gas vs. venous blood gas

This is another article regarding comparison of VBG vs ABG. “Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 in initial emergency department assessment”. The other one was in critically ill patient but this one is among patient with diverse medical conditions. Read More …

Prehospital Epinephrine Use and SurvivalAmong Patients With Out-of-Hospital Cardiac Arrest

In October 2011, I reviewed an interesting article in Resuscitation, September 2011 regarding use of Epinephrine in per-hospital setting, ,now we have another study published in JAMA, March 2012. Read More …

Pan-Scan for detection of injuries in patients with major blunt trauma

We usually make fun of this topic such as how about have a ct scan in triage and etc.. This is a European study that shows the pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Link to article

Clindamycin or Bactrim for pediatric skin and soft-tissue infections

This is a retrospective cohort study between 2004-2007 among patients who received a treatment with clindamycin, trimethoprim-sulfamethoxazole, or a β-lactam for their skin and soft-tissue infections. Read More …

Guidelines for the Assessment and Management of Anaphylaxis

I am teaching this topic to medical students, interns, and residents every month and I found this valuable guideline by World Allergy Organization.  Read More …

Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus

This study is interesting because Maryland EMS has a protocol to give Midazolam IM in prehospital setting. The New England journal published on Feb,16, 2012 a double-blind, randomized study comparing IM Midazolam versus IV Lorazepam for children and adults in status epilepticus. Read More …

Bleeding in patients using new anticoagulants or antiplatelet agents: risk factors and management

This is a link to an article form Netherlands, on management of bleeding in patients who just started on different antiplatelet agents.  Read More …

Normalization of Vital Signs Does Not Reduce the Probability of Acute Pulmonary Embolism

Jeffry Kline is famous for his research on PE and his latest article in Academic Journal of Emergency Medicine(Jan 2012) is opening another window to PE regarding Normalization of Vital Signs Does Not Reduce the Probability of Acute Pulmonary Embolismin Symptomatic Emergency Department Patients.

Read More …

Focused Cardiac Ultrasound in the Emergent Setting

American Society of Echocardiography (ASE) and the American College of Emergency Physicians (ACEP) described the important role of focused cardiac ultrasound (FOCUS) in patient Read More …

Hyperglycemia in Hospitalized Patients, An Endocrine Society Clinical Practice Guideline

The Journal of Clinical Endocrinology & Metabolism published a practice guideline in Jan.2012. Focus of this guideline is management of hyperglycemia in Read More …

Seizure? Look for PE!!!

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

 

 

Effective Antibiotic Treatment Prescribed by Emergency Physicians in Severe Sepsis or Septic Shock

Journal of Emergency Medicine published an article with title of “Effective Antibiotic Treatment Prescribed by Emergency Physicians in Patients Admitted to the Intensive Care Unit With Severe Sepsis or Septic Shock” in Dec,2011. Read More …

Cardiac arrest and prognosis

 

This is one of the challenging topics in EM. when should you stop CPR? what parameters do you have to continue versus terminate CPR? Read More …

Cervical Spine MRI in Alert, Neurologically Intact Trauma Patients

Probably  you had this dilemma before. Patient involved  MVC with midline neck tenderness and negative CT scan. Now, what should I do? Should I clear and remove c-collar or consult with trauma.  There are 2 approaches that trauma surgeons usually do. 1:MRI and/or 2: Flex-ex xray. Read More …

Prediction of Pneumonia in a Pediatric Emergency Department

I thought I posted this before but I did not, Pediatrcis 2011, prospective cohort study with 2574 patients under 21 years old. Interestingly, 16 % of patients had radiographic pneumonia. Read More …

Emergency Hospitalizations for Adverse Drug Events

To estimate the frequency and rates of hospitalization after emergency department visits for adverse drug events in older adults between 2007-2009. Read More …

New LBBB and STEMI

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 …

Actual or the corrected serum sodium in DKA!

The anion gap is representative of positive versus negative charges. when we are calculating anion gap, we are calculating a balance between positive and negative charges. correcting Read More …

MRSA Therapy! New Guideline

IDSA (Infectious Diseases Society of America) published a new guideline this year for treatment of soft tissue infections and MRSA. Read More …

Kocher Criteria

Kocher Criteria is the best way to diagnose septic arthritis in children Read More …

Lumbar Puncture in febrile infant

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 …

CO Poisoning

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 …

Children at very low risk of TBI per PEACRN

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 …

Pediatric UTI; Practice guideline from AAP

Recently, AAP published a practice guideline on “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children  Read More …

Are arterial and venous samples clinically equivalent….

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 …

Effect of adrenaline on survival in out-of-hospital cardiac arrest

This is a very interesting study regarding usage of epinephrine in out of hospital setting.  This is probably the first control trial in human post cardiac arrest. The study is about Read More …

Volume Status in Septic Shock

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 …

Diagnostic Accuracy of VBG in DKA

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 …

Top Ten Documentation Mistakes

ACEP’s Video presentation of Dr. Greg Henry and Dr. Gillian Schmitz discussing the top ten documentation mistakes.

Fast Track

How to do Lung Ultrasound to rule out Pneumothorax!

1. Select your probe:
Linear probe, or vascular probe with low penetration and high frequency.

 
Read More …

Lung ultrasound in critically ill patients

Lung ultrasound in critically ill patients: Comparison with bedside chest radiography. This study was done in Greece and their finding is in general ICU population lung ultrasound Read More …

Welcome to Emergency Medicine Education

Welcome to Emergency Medicine Education(EME). This is my first post. Finally, after a long way, I created something under my name. I hope you enjoy visiting this website and I(we) can give some Evidence Based Medicine (EBM) through this site. Ali


Hit Counter provided by iphone 5