Emergency Medicine Education

Dilaudid (Hydromorphone), How much?

Pourmand — Sat, 08 Jun 2013 13:47:27 +0000

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. Recent article in Annals studied an interesting method to administer Dilaudid, it called 1+1, instead of giving a bolus of 2 mg Dilaudid they proposed 1mg and then assess patients pain after 15 min and if needed re-dose the patient. in 1+1 group , 50 % less opioid needed to have satisfactory analgesia.

Link to Article

Lumbar Puncture

Pourmand — Mon, 03 Jun 2013 17:19:49 +0000

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

Pourmand — Sun, 02 Jun 2013 20:07:21 +0000

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 in 67%. we should remember that these kids did not have any pain or TTP in RLQ. This study showed visualization was not affected by: BMI, age, or gender.

Link to article

Subarachnoid Hemorrhage Dillema, LP or Not To LP

Pourmand — Tue, 28 May 2013 00:17:28 +0000

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

Pourmand — Mon, 04 Mar 2013 15:06:30 +0000

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. They observed that patients with A-fib and other primary ED diagnosis have mortality rate higher than patients with ED diagnosis of A-fib, and surprisingly mortality rate was 3 times more in patients with A-fib who had alternative ED diagnosis.

Link to Article

PCN resistant Gonorrhea

Pourmand — Sat, 23 Feb 2013 15:42:02 +0000

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

From CDC Site:
Treatment for Gonorrhea at any anatomic site : a single 250 mg intramuscular dose of ceftriaxone + either 1 g of azithromycin as a single oral dose or 100 mg of doxycycline orally twice daily for 7 days. If this recommended regimen cannot be used, two alternative treatment options exist for urogenital or rectal gonorrhea:

1) if ceftriaxone is not available, clinicians can consider cefixime 400 mg as a single oral dose and either azithromycin 1 g as a single oral dose or doxycycline 100 mg orally twice daily for 7 days, or

2) if the patient is cephalosporin-allergic, clinicians can consider azithromycin 2 g as a single oral dose. If either of these two alternative regimens is prescribed, the patient should return in 1 week for a test of cure.

Link to Full Text

Oral Contrast and LOS

Pourmand — Wed, 20 Feb 2013 04:16:49 +0000

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

who are insisting on Oral contrast to diagnose Appendicitis, Diverticulitis and SBO.

Link to article

Abdominal 64-MDCT for suspected appendicitis: the use of oral and IV contrast material versus IV contrast material only.

Does enteral contrast increase the accuracy of appendicitis diagnosis?

A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults.

Neutral vs positive oral contrast in diagnosing acute appendicitis with contrast-enhanced CT: sensitivity, specificity, reader confidence and interpretation time.

ACEP Clinical Policy: Asymptomatic HTN in ED

Pourmand — Wed, 20 Feb 2013 04:09:19 +0000

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:

1. In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?

2. In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?

ACEP: Clinical Policy

Ketorolac in the Treatment of Acute Migraine: A Systematic Review

Pourmand — Fri, 01 Feb 2013 23:23:54 +0000

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:
“Ketorolac should not be the first agent for treating migraine but is more effective than sumatriptan; but it may not be as effective as metoclopramide/phenothiazine agents.”

If you are interested to read more, “Headache” in March 2012 had another study regarding Migraine “Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications.”
One of their conclusions was “Metoclopramide was equivalent to prochlorperazine, and, when combined with diphenhydramine, was superior in efficacy to triptans and NSAIDs.” we had a study in Annals of Emergency Medicine for combination of Metoclopramide and Diphenhydramine.

Link to Headache

Challenges regarding Troponin

Pourmand — Fri, 04 Jan 2013 01:48:26 +0000

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.

2. Elevated troponin is a sensitive and specific indication of cardiac myonecrosis, with troponin release from myocytes into the systemic circulation, but Troponin elevation occurs in many nonischemic clinical conditions such as:

a. Hypoxemia
b. right ventricular (RV) pressure overload following a PE
c. heart failure
d. CKD,
e. sepsis
f. thermal injury
g. blunt cardiac trauma
h. SAH
and you know about endocarditis, chronic lung diseases and …

3. we discussed this before: the role of CAD (MI) and ESRD and Troponin, but again: Dynamic changes in troponin values of ≥20% over 6 to 9 h should be used to define acute MI in ESRD patients.

Very , Very Very Important:

4. “In the large, multicenter ADHERE (Acute Decompensated Heart Failure Registry) National database, 81% of patients admitted with heart failure had troponin testing, and nearly 6.2% of patients had abnormal troponin test results (troponin I ≥1.0 μg/l or troponin T ≥0.1 μg/l) after excluding patients with serum creatinine >2.0 mg/dl . Hospital mortality among troponin-positive patients was 8.0%, compared with 2.7% among troponin-negative patients (adjusted odds ratio [OR]: 2.55) and was independent of an etiology of heart failure (ischemic or nonischemic)”.

Our job is not to risk stratify Patient with Heart Failue in ED with high troponin

Link To Full Text