Norepinephrine In Blunt Trauma and Hemorrhagic Shock

Based on this European study that involved colleagues from France, Italy, Switzerland included 2164 patients, 69% needed emergency hemorrhage control, 6 % received prehospital PRBC transfusion, 25% had massive transfusion. They concluded that “early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock.” Link to article

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Double Sequential Defibrillation, Yay or Nay!

When we published our review “The controversial role of dual sequential defibrillation in shockable cardiac arrest”, our conclusions was further studies are necessary to assess the efficacy and safety of DSD compared to the standard of care treating refractory VF. AEM published another study exactly one year later: Prehospital Double Sequential Defibrillation: A Matched Case-Control […]

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Levetiracetam versus phenytoin?

Levetiracetam versus phenytoin? Which one do you use in case of status epilepticus in children? A multicentre, open-label, randomised trial publishe by the Lancet suggests that levetiracetam could be an alternative “as the first-choice, second-line anticonvulsant in the treatment of paediatric convulsive status epilepticus.” Link to article

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HOUR and Opioid OD Disposition!

When do you discharge a patient with opioid OD? Is it awake, alert ox3, Passed road test, articulate well? AEM published a prospective clinical prediction rule to assess when a patient is ready to be discharged! Hospital Observation Upon Reversal (HOUR) with naloxone will assess patients one hour after administration of prehospital naloxone. Six criteria […]

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Intubation during cardiac arrest!

We know interruptions during cardiac arrest will have a worse outcome but intubation during a cardiac arrest for several reasons decreased survival rate among these patients. JAMA study measured good functional outcome among patients were intubated during the first 15 minutes and who were not intubated within the first 15 minutes! JAMA Full text

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Biphasic Allergic Reaction

We reviewed this topic here, and we published our review in AJEM. Now Anesthesiology in Feb published a study from ICU with the same topic. Patients admitted to the hospital for a biphasic allergic reaction was observed in ICU and 4/83 (5 %, 3 possible, 1 probable) of patients experienced a mild recurrent reaction and […]

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Dealing with agitated patient in ED

ACEP Now published a 5-Step Approach to the Agitated Patient in Nov. 2018, I believe this is a very good resource for our resideints. The 5 steps are categorizing agitation as mild, moderate, or severe, nonpharmacologic de-escalation for mildly or moderately agitated patients, “code white” for moderately and severely agitated patients, safe and effective physical […]

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Medication for Acute Agitation

What is your choice of IM medication for a patient who is very difficult to verbally be redirected, and being agitated, combative, and required to be sedated? Happy to see the old practice is still effective: Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department Ann Emerg Med. 2018 Jun […]

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Oral Acetaminophen or IV Acetaminophen

BMJ published a a prospective, double-blind, double-dummy, randomised controlled trial regarding Intravenous versus oral Acetaminophen. 87 participants were enrolled. No superiority was demonstrated in this trial with 1 gram intravenous acetaminophen compared with 2 x 500 mg oral acetaminophen in terms of efficacy of analgesia and no difference in length of stay, patient satisfaction, need […]

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Calcium Channel Blocker or Adenosine for SVT

I had  a patient with perisstent Supraventricular tachycardia (SVT). My approach usually starts with REVERT, and if unsuccessful will continue with Adenosine. Adensoine with its rapid onset, and short half-life regardless of teribble expeince for patient is a great medication, but in this particular patient in 2 occasions was converting SVT to Sinus rhythm and after […]

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Dexamethasone and Sore Throat

Is Dexamethasone an option to treat sore throat ? A JAMA study on 565 patients in a randomized  clinical trial showed “a single dose of oral dexamethasone(10 mg) compared with placebo did not increase the proportion of patients with resolution of symptoms at 24 hours. However, there was a significant difference at 48 hours.” Link […]

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The Canadian Syncope Arrhythmia Risk Score

Another Canadian risk score published in AEM, discussing Short-term Risk of Arrhythmia among Patients With Syncope. This is a multicenter prospective cohort study with 5,010 patients. This study had very good sensitivity: 97% and very poor specificity 53%. Please take a look at the study for 39 different variables that they considered. Link to Abstract

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I-PASS

“Sign out”, “Hand off” is one of the critical action for EM physicians. SBAR (Situation, Background, Assessment, Recommendation) is one of the famous procedure to standardize this action. I-PASS initially came for Pediatric literature is an alternative way to summarize and give some standardize protocol for hand off. Pediatrics Academic Medicine

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Mono or Dual Therapy for Cellulitis

It is very interesting that how fast we are changing our practice lately. Still remember when we started to give double dose of TMP/SMZ plus cephalexin for cellulitis, and then we changed it to 1 dose of TMP/SMZ + cephalexin and then we doubted if cephalexin is necessary or not. JAMA published a randomized study […]

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Tamsulosin and Kidney Stone

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 larger stones. Wang RC et al. Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis. Tamsulosin significantly improves stone passage […]

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Ketorolac, How much is enough?

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 minutes. This study did not go over 2 hrs and does not give us any information regarding prolonging pain medication, but for acute onset pain […]

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HAP and VAP not HCAP!

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.” There are some answered questions that previously we were practicing based on them. I. Should Patients With Suspected VAP Be Treated Based on the Results […]

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COPD and risk of PE

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 in unexplained acute exacerbation of COPD reported as high as 16%. We should be worry about PE in patients with unexplained acute exacerbation of COPD […]

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FAST-ED for LVOS!

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 Triage for Emergency Destination (FAST-ED) extracted from NIHSS. LVOS were defined by total occlusions involving the intracranial ICA, MCA-M1, MCA-2, or basilar arteries. FAST-ED scoring […]

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COPD and NIV

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 deal with NIV machine and also setting initial parameter. This is augment our practice that how to approach COPD patient in ED with NIV. Link […]

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Headache Treatment!

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 happy to see our routine practice to treat headache in ED, now after years is coming to Neurology Guideline! Metoclopramide and prochlorperazine offered as level […]

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Prednisone and Dexamethasone for Asthma

Can we use Dexa instead of Prednisone when we are discharging patient home? old question and as I remember the answer was always Sure! but why are we asking still this question: Symptomatic improvement following emergency department management of asthma: a pilot study of intramuscular dexamethasone versus oral prednisone. J. Asthma 1997 2 articles within […]

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Chest pain and ACS

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 in ED! Patient presented to ED with chest pain evaluated from 1995 to 2015. History, physical exam, ECG, clinical decision rule and Troponin were examined […]

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COPD and Beta Blocker and Contraindication!

We all shaky when we want to start Beta Blocker in COPD Patients! One of the traditional contraindication in COPD patients is using Beta Blcoker, Thorax BMJ reported a study that was done in US and showed betal blockers are  associated  with a significant reduction in COPD exacerbations regardless of severity of airflow obstruction.   […]

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Epinephrine, Is it still alive?!!!

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 Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest 2014: Is Epinephrine During Cardiac Arrest Associated With Worse Outcomes in Resuscitated Patients? and now […]

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Blood Pressure Target in ICH

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 sure the exact number or acceptable number to drop BP but obviously, we should not be worried to drop SBP in hypertensive hemorrhagic stroke as […]

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NSAIDS and Osteoarthritis Pain

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 do anything with pain. Lancet in a meta-analysis compared NSAIDs, Acetaminophen, or placebo. They concluded that Diclofenac 150 mg/day is the most effective NSAID available […]

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Unnecessary Medical Screening Tests

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? We did not go to medical school to being uncomfortable, we went to medical school to be comfortable , but I don’t think that we […]

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Gout and Steroids!

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 indomethacin or prednisolone for 5 days. The regimen was for patients presented to the ED within 3 days of symptom onset. Indomethacin group: patients received […]

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Contrast Induced Nephropathy!

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? American College of Radiology onContrast Media in 2015 “At the current time, there is very little evidence that IV iodinated contrast material is an independent […]

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Nasal Cannula and Pre-oxygenation

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 Healthy volunteers ,30 nonrebreather face mask and 30 bag-valve-mask. There will be an argument that Healthy lungs will be different from patients with restrictive or […]

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Migraine and Diphenhydramine!

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 “Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department–Based Randomized Clinical Trial”. I am not sure that I am ready to start practicing this […]

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Venous Blood Gas, You Rock!

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 and we had VBG! My old Post was focused mostly on DKA patient but Thanks to Throax that published a study among COPD patients. Using […]

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Seizure: Loading Dose

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 active seizure should receive Phenytoin 15- 25 mg/kg no more than 50 mg/min. For patient in no active seizure: Without a loading dose, phentoin may […]

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EKG and PE!

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 patients and found the most EKG findings among patients whom was diagnosed with acute PE: tachycardia (38%), T-wave inversion in lead V1 (38%), and ST […]

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Choice of Treatment for Uncomplicated UTI

Sounds like we have to move from Bactrim and Cipro to other agents for uncomplicated cystitis. AJEM published an article in Sept and recommends using more local agent for uncomplicated cystitis , instead of systemic antibiotics. The antibiogram in this study showed sensitivity to Trimethoprim-Sulfamethoxazole 75%, Ciprofloxacin  80%, Nitrofurantoin99%, and Cefazolin 96%.   AJEM Abstract […]

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Back Pain and Narcotics!

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 on this, but I have to accept that in clinical setting, its difficult to convince some patients that narcotics are not the best approach for […]

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Appendicitis OR versus IV antibiotics!

There are a lot confusion/controversy regarding appendicitis treatment :ABx vs surgery: The NOTA Study (Non Operative Treatment for Acute Appendicitis) in Ann surg, 2014 showed that antibiotics for suspected acute appendicitis are safe and effective and may avoid unnecessary appendectomy. Long-Term Outcomes of Patients with Nonsurgically Managed Uncomplicated Appendicitis in J Am Coll Surg, 2014 […]

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Stroke, ED is the best Place to Go!

Recent post in NY Times,  Stroke of Fate , offended many ED physicians. I was not! It was very simple to me. A 78 years old neurologist said “I’m afraid to go to the emergency room,” he added. “I think it’s dangerous.” I agree that this is not a good comment for general population to […]

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Just Wait to Pre-oxygenate!

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.

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Are we done with CT/LP to rule out SAH?

The BMJ study was a shocking news in 2011 regarding Sensitivity of Modern CT scan in diagnosis of SAH within 6 hours of presentation, Click here for more Then, Storke in 2012 reported another study that showed there is “no added value of CSF analysis to detect SAH within 6 hours of patient presentation with […]

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