Category: PGY4

A very great review regarding new onset seizure and systematic approach. Unfortunately, lacking ED setting, but worthwhile reading it. Interestingly, from 8% to 10% of the population will experience a…

Neurology PGY1 PGY2 PGY3 PGY4

Orthopedics PGY1 PGY2 PGY3 PGY4

There are 3 recent studies regarding this subject: Hollingsworth et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. The greatest benefit might be among those with…

PGY1 PGY2 PGY3 PGY4 Urology

Annals of Emergency Medicine in a study published in Dec 2016 showed that there is no association between discharge glucose and 7 days outcome! Link to article

Diabetes PGY1 PGY2 PGY3 PGY4

A randomized double-blind study published in Annals of emergency medicine showed that Ketorolac in doses of 10, 15, or 30 mg intravenously has no differences in terms of analgesic effect at 30…

PGY1 PGY2 PGY3 PGY4

The new guideline by IDSA published’ Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.”…

Infectious Disease PGY1 PGY2 PGY3 PGY4 Pulmonary

Lancet Published a study from Qatar and Australia, comparing Diclofenac Vs Morphine Vs Acetaminophen! Not surprising still NSAIDs are promising to control the symptoms.   Link to article

PGY1 PGY2 PGY3 PGY4 Urology

PGY1 PGY2 PGY3 PGY4 Pulmonary

I think everyone is practicing based on Hb&Hct threshold. We have great studies show Hb of 7 could be the trigger point to start for blood transfusion. The latest publication…

Hematology PGY1 PGY2 PGY3 PGY4

Chest published an article regarding risk of chronic pulmonary obstructive disease and pulmonary embolism. There are different reported risk from 3% to 30%. In this study, prevalence of pulmonary embolism…

PGY1 PGY2 PGY3 PGY4 Pulmonary VTE

Cardiology PGY1 PGY2 PGY3 PGY4 Pulmonary VTE

Large Vessel Occlusion Stroke (LVOS) is  an indication for activating stroke team. IR will be on board and this is level IA recommendation from 2015 AHA/ASA Guideline. The Field Assessment Stroke…

Neurology PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Trauma

British Thoracic Society/Intensive Care Society published a guideline regarding ventilatory management of acute hypercapnic respiratory failure(AHRF). I believe there are good recommendations for junior residents who do not know to…

PGY1 PGY2 PGY3 PGY4 Pulmonary

Infectious Disease PGY1 PGY2 PGY3 PGY4

Expert panel from American Headache Society Published a guideline! to manage Migraine Headache in ED in Headache June 2016. They searched and found 68 randomized controlled trials. I am very…

Neurology PGY1 PGY2 PGY3 PGY4

Neurology PGY1 PGY2 PGY3 PGY4

Infectious Disease PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Pulmonary

One of our favorite question in ED is: “Does this patient with chest pain have ACS?” JAMA in Nov. 2015 tried to answer this question from the eyes of cardiologist…

Cardiology PGY1 PGY2 PGY3 PGY4

General EM PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Pulmonary

It has been a very difficult time for Epi since last 5 years! 2011: Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial 2012: Prehospital…

Cardiac arrest PGY1 PGY2 PGY3 PGY4

Cardiac arrest PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Pulmonary

There are a lot of controversies around this topic, but It sounds like lowering blood pressure is safe, the following Stroke link recommend SBP 140 is safe, I am not…

Neurology PGY1 PGY2 PGY3 PGY4

What is your choice to treat chronic joint pain? I know! It is very frustrating for patients and physicians, I took 800mg of Motrin but… and you know Narcotics wont…

Orthopedics PGY1 PGY2 PGY3 PGY4

I would like to quote this again from Dr. Oslser “The good physician treats the disease; the great physician treats the patient who has the disease”.  Are we following him?…

PGY1 PGY2 PGY3 PGY4

Infectious Disease PGY1 PGY2 PGY3 PGY4

Annals of Internal Medicine published a Multicenter, Double-Blind, Randomized Trial and compared Oral Prednisolone in the Treatment of Acute Gout. Patients were randomly assigned in a 1:1 ratio to receive either…

Orthopedics PGY1 PGY2 PGY3 PGY4

JAMA Published The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) by Physicians from USA, Germany, France, Australia, Canada, Netherlands, and Belgium. The reason for this new definition…

Infectious Disease PGY1 PGY2 PGY3 PGY4 Sepsis

Found this link in Diagnosis and also in Acad Medicine regarding Patient/Provider safety and how to reduce diagnostic error. also what to do in high risk situations. Take a look…

PGY1 PGY2 PGY3 PGY4

Is it real? we had this discussion before: Aortic dissection and contrast, Vertebral artery dissection and contrast, any VTE disease and contrast. but what should be our target GFR, Cre?…

PGY1 PGY2 PGY3 PGY4 Radiology

If we add nasal cannula to nonrebreather face mask or BVM with air leak, we will improve pre-oxygenation phase. This study that just published in Annals of EM enrolled 6o…

PGY1 PGY2 PGY3 PGY4 Pulmonary

PGY1 PGY2 PGY3 PGY4 Pulmonary

There is a very good review of managing shoulder dislocation. It is not EBM, but worth to read.

Orthopedics PGY1 PGY2 PGY3 PGY4

I am fan of Metoclopramide + Diphenhydramine  or Prochlorperazine + Diphenhydramine for Migraine Headache, and I see a lot of good outcome among patients with headache. Annals of EM published…

Neurology PGY1 PGY2 PGY3 PGY4

Neurology PGY1 PGY2 PGY3 PGY4

We had a long journey to get here! I can’t tell how many times that I had argument with consultants regarding COPD or DKA patient that they ask for ABG…

PGY1 PGY2 PGY3 PGY4 Pulmonary

There are several methods to orally load Anti Epileptic drugs (AED) in ED. Tintinalli’s has 2 approaches: 1.patient with active seizure 2. patient with history of seizure. Patient who had…

Neurology PGY1 PGY2 PGY3 PGY4

I cannot say that  we did not know about this, but having an article to support this is very exciting. Jeff Kline and his colleagues analyzed 45 studies of 8,209…

Cardiology PGY1 PGY2 PGY3 PGY4

Neurologic clinics has a very nice article regarding BPPV. It explains not only the epidemiology and Etiology , it also discusses the diagnosis maneuver and also treatment options. Link to…

Neurology PGY1 PGY2 PGY3 PGY4

Infectious Disease PGY1 PGY2 PGY4

We all see patients with back pain every single day that we are working in ED. Many of them tried different pain medications, muscle relaxant. I have had several presentations…

Orthopedics PGY1 PGY2 PGY3 PGY4

airway PGY1 PGY2 PGY3 PGY4

Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society answers  very critical questions regarding unprovoked first seizure.

PGY1 PGY2 PGY3 PGY4 Seizure

Anaphylaxis PGY1 PGY2 PGY3 PGY4

Infectious Disease PGY1 PGY2 PGY3 PGY4

Having a pregnant patient with suspected PE, you know what I’m talking about. It is usually a disaster, mom is worry about fetus, dad is worry about mom, you are worry about both! how much is the risk of PE in pregnancy?

PGY1 PGY2 PGY3 PGY4 Pulmonary

GI PGY1 PGY2 PGY3 PGY4

Cardiac arrest PGY1 PGY2 PGY3 PGY4

Troponin 1 set, 2 sets, 3 sets, Stress test, Echo, Observation vs Admission. LOW risk chest pain, when will be a safe practice. JAMA internal medicine in March found patients that they do not have

Cardiology PGY1 PGY2 PGY3 PGY4

Cardiology PGY1 PGY2 PGY3 PGY4

Cardiology PGY1 PGY2 PGY3 PGY4

I usually review a question on my board review series regarding a patient with trauma and negative x-ray of hip, what is the next step? The answer is usually CT scan, and I have to admit that this is my routine practice that I do not rely on X-ray, if my patient still is symptomatic,

Orthopedics PGY1 PGY2 PGY3 PGY4

Neurology PGY1 PGY2 PGY3 PGY4

Just published regarding high-flow nasal cannula oxygenation, and I just published last Post. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: A randomized controlled clinical trial,

airway PGY1 PGY2 PGY3 PGY4

I believe sometimes we are in rush for no reason. Patient with hypoxia and no reserve requires some oxygen to prevent hypoxia during intubation, DSI vs RSI. I am fan of DSI to buy some time to see how we could assist with oxygenation before definitive airway intervention.

airway PGY1 PGY2 PGY3 PGY4

You can find in this blog at least 6 references talking about Contrast vs Non contrast CT, but this new study in Annals of EM showed the same result that oral contrast in detecting intra-abdominal pathologies is useless. Wow, this is a big word. USELESS.

PGY1 PGY2 PGY3 PGY4 Trauma

Neurology PGY1 PGY2 PGY3 PGY4

SIRS criteria an immune response to infection can be diagnosed by ( 96.8<Temp>100.4, HR>90, RR>20 and 4K<WBC>12k). A new study  in 172 ICUs among 109,663 patients with infection and

PGY1 PGY2 PGY3 PGY4 Sepsis

Surviving Sepsis Campaign updated its guideline regarding new evidence (ProCESS, ARISE, ProMIS). It is required to do a series of actions within first 3 hours and 6 hours of patient presentation(time of triage):

PGY1 PGY2 PGY3 PGY4 Sepsis

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.

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

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

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.

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

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

General EM PGY1 PGY2 PGY3 PGY4

PGY1 PGY2 PGY3 PGY4 Trauma

ENT PGY1 PGY2 PGY3 PGY4

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?

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.

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!…

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!!!

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.

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:

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…

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.

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.

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,

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

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,

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

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!

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

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

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? 😉

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

Neurology PGY1 PGY2 PGY3 PGY4

Neurology PGY1 PGY2 PGY3 PGY4