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  1. Cardiac Risk factors, How important are they?

    April 9, 2014 by Pourmand

    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 (more…)


  2. Still MAP of 65 Works!

    April 9, 2014 by Pourmand

    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 (more…)


  3. EGDT or ProCESS , That is the question!

    March 20, 2014 by Pourmand

    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 (more…)

  4. ACEP Practice Guideline on Procedural Sedation

    February 7, 2014 by Pourmand

    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:

    (more…)


  5. Glucagon and Food bolus

    February 3, 2014 by Pourmand

    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? ;) (more…)


  6. INR overestimates coagulopathy in stable trauma and surgical patients

    January 24, 2014 by Pourmand

    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. (more…)


  7. JNC 8 is Out! New definnition of Hypertension!

    January 15, 2014 by Pourmand

    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). (more…)


  8. Blood Pressure Reduction and Acute Ischemic Stroke

    January 1, 2014 by Pourmand

    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 (more…)

  9. Headache and Common Questions

    November 24, 2013 by Pourmand

    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. (more…)

  10. Discharge Against Medical Advice, Pitfalls and Ttroubleshooting

    November 17, 2013 by Pourmand

    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. (more…)


  11. Bronchitis; Antibiotics or No Antibiotics, That is the question

    November 12, 2013 by Pourmand

    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

    (more…)


  12. What is the optimal dose of Ketorolac as pain medication?

    October 17, 2013 by Pourmand

    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. (more…)


  13. Worsening Trends in the Management and Treatment of Back Pain

    October 16, 2013 by Pourmand

    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.  (more…)


  14. Shoulder Dislocation and complications

    August 18, 2013 by Pourmand

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


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

    July 18, 2013 by Pourmand

    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 (more…)


  16. Dilaudid (Hydromorphone), How much?

    June 8, 2013 by Pourmand

    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. (more…)


  17. Lumbar Puncture

    June 3, 2013 by Pourmand

    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

     


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

    June 2, 2013 by Pourmand

    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 (more…)


  19. Subarachnoid Hemorrhage Dillema, LP or Not To LP

    May 27, 2013 by Pourmand

    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.

     


  20. Mortality of Patients With Atrial Fibrillation and an Alternative Primary Diagnosis

    March 4, 2013 by Pourmand

    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. (more…)


  21. PCN resistant Gonorrhea

    February 23, 2013 by Pourmand

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

    (more…)


  22. Oral Contrast and LOS

    February 19, 2013 by Pourmand

    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

    (more…)


  23. ACEP Clinical Policy: Asymptomatic HTN in ED

    February 19, 2013 by Pourmand

    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:
    (more…)


  24. Ketorolac in the Treatment of Acute Migraine: A Systematic Review

    February 1, 2013 by Pourmand

    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: (more…)


  25. Challenges regarding Troponin

    January 3, 2013 by Pourmand

    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. (more…)


  26. CO Poisoning, New pracice guideline

    December 4, 2012 by Pourmand

    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: (more…)


  27. aVR: The most Ignored Lead

    October 23, 2012 by Pourmand

    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


  28. Typical Vs Atypical Chest pain

    October 19, 2012 by Pourmand

     

    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 (more…)


  29. CONTRAST CT or NON CON CT?

    October 2, 2012 by Pourmand

    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


  30. Transient Ischemic Attack

    October 1, 2012 by Pourmand

    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%). (more…)


  31. Hypertension treatment

    August 19, 2012 by Pourmand

    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) (more…)


  32. Cardiac Arrest Survival Is Rare without Prehospital Return of Spontaneous Circulation

    August 14, 2012 by Pourmand

    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 (more…)


  33. Early Administration of Systemic Corticosteroids in Children With Asthma Exacerbation

    July 24, 2012 by Pourmand

    July 2012: Annals of Emergency Medicine:

    Early Administration of Systemic Corticosteroids Reduces (more…)


  34. Complications Associated with Sickle Cell Trait

    June 24, 2012 by Pourmand

    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, (more…)


  35. EKG differentiation of early Repol vs STEMI

    June 4, 2012 by Pourmand

    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!!! (more…)


  36. SYNCOPE vs Near SYNCOPE

    May 20, 2012 by Pourmand

    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


  37. Low Back Pain

    May 17, 2012 by Pourmand

    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


  38. New Concepts in the Assessment of Syncope

    May 16, 2012 by Pourmand

    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


  39. What is the role of Morphine in Flash Pulmonary Edema?

    May 11, 2012 by Pourmand

    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.  (more…)


  40. Standards of Medical Care in Diabetes: 2012

    April 15, 2012 by Pourmand

    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

     

     

     


  41. Comparison of arterial blood gas vs. venous blood gas

    April 15, 2012 by Pourmand

    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. (more…)


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

    April 6, 2012 by Pourmand

    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. (more…)


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

    March 19, 2012 by Pourmand

    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


  44. Clindamycin or Bactrim for pediatric skin and soft-tissue infections

    March 5, 2012 by Pourmand

    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. (more…)


  45. Guidelines for the Assessment and Management of Anaphylaxis

    March 1, 2012 by Pourmand

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


  46. Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus

    March 1, 2012 by Pourmand

    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. (more…)


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

    February 20, 2012 by Pourmand

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


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

    February 19, 2012 by Pourmand

    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.

    (more…)


  49. Focused Cardiac Ultrasound in the Emergent Setting

    February 5, 2012 by Pourmand

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


  50. Hyperglycemia in Hospitalized Patients, An Endocrine Society Clinical Practice Guideline

    January 23, 2012 by Pourmand

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


  51. Seizure? Look for PE!!!

    January 14, 2012 by Pourmand

    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

     

     


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

    January 14, 2012 by Pourmand

    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. (more…)


  53. Cardiac arrest and prognosis

    December 22, 2011 by Pourmand

     

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


  54. Cervical Spine MRI in Alert, Neurologically Intact Trauma Patients

    December 16, 2011 by Pourmand

    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. (more…)


  55. Prediction of Pneumonia in a Pediatric Emergency Department

    December 14, 2011 by Pourmand

    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. (more…)


  56. Diagnosis and Therapy of Massive PE

    December 4, 2011 by Pourmand

     

     


  57. Emergency Hospitalizations for Adverse Drug Events

    December 4, 2011 by Pourmand

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


  58. New LBBB and STEMI

    November 28, 2011 by Pourmand

    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. (more…)


  59. Actual or the corrected serum sodium in DKA!

    November 22, 2011 by Pourmand

    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 (more…)


  60. MRSA Therapy! New Guideline

    November 16, 2011 by Pourmand

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


  61. Kocher Criteria

    November 13, 2011 by Pourmand

    Kocher Criteria is the best way to diagnose septic arthritis in children (more…)


  62. Lumbar Puncture in febrile infant

    November 13, 2011 by Pourmand

    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 (more…)


  63. bedside Ultrasound and cardiac mass

    November 11, 2011 by Pourmand

    This is my case report with Keith Boniface on cardiac angio-sarcoma:

    Incidental Identification of Right Atrial Mass Using Bedside Ultrasound: Cardiac Angiosarcoma

     


  64. CO Poisoning

    November 5, 2011 by Pourmand

    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: (more…)


  65. Children at very low risk of TBI per PEACRN

    November 1, 2011 by Pourmand

    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. (more…)


  66. Pediatric UTI; Practice guideline from AAP

    October 31, 2011 by Pourmand

    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  (more…)


  67. Are arterial and venous samples clinically equivalent….

    October 27, 2011 by Pourmand

    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 (more…)


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

    October 22, 2011 by Pourmand

    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 (more…)


  69. Volume Status in Septic Shock

    October 22, 2011 by Pourmand

    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 (more…)


  70. Top Ten Mistakes in Residency

    October 21, 2011 by admin

    Top Ten Mistakes in Residency
    by: Peter Deblieux


  71. Diagnostic Accuracy of VBG in DKA

    October 19, 2011 by Pourmand

    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.

    (more…)


  72. SURVIVING SEPSIS CAMPAIGN GUIDELINES

    October 11, 2011 by Pourmand


    2008 Pocket Guides, Surviving Sepsis Campaign Guideline


  73. Top Ten Documentation Mistakes

    October 11, 2011 by Pourmand

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


  74. EKG interpretation Recognizing STEMI

    October 10, 2011 by Pourmand


  75. Emergency Medicine Past and Future

    October 10, 2011 by Pourmand

    Emergency-Medicine-Past-and-Future
    by: Peter Rosen


  76. Fast Track

    October 10, 2011 by Pourmand

    How to do Lung Ultrasound to rule out Pneumothorax!

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

     
    (more…)


  77. Lung ultrasound in critically ill patients

    October 6, 2011 by Pourmand

    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 (more…)


  78. Anaphylaxis and Angioedema

    October 6, 2011 by Pourmand


  79. Which Anti-emetic for Undifferentiated Vomiting

    October 6, 2011 by Pourmand

    Which Anti-emetic for Undifferentiated Vomiting
    By: Ingrid Lim


  80. Welcome to Emergency Medicine Education

    October 4, 2011 by admin

    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