Glucose threshold to discharge a patient with hyperglycemia!
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
Continue ReadingAuthor: Pourmand
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 […]
Continue ReadingHAP 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 […]
Continue ReadingNSAIDS for Renal Colic!
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
Continue ReadingNew Guideline on Antithrombotic Therapy!
Choices of anticoagulation therapies are not simple as it was before, it does not mean that it was safer before. The new guideline from CHEST gave Level 2B recommendations to the new generation of NOVACs. Dabigatran (Grade 2B), Rivaroxaban (Grade 2B), Apixaban (Grade 2B), or Edoxaban (Grade 2B) was reviewed. Link to article
Continue ReadingBlood Transfusion Threshold!
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 from JAMA showed that we are in a right direction in our practice. Link to article
Continue ReadingCOPD 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 […]
Continue ReadingShock Prediction with 12 Lead ECG in Pulmonary Embolism!
This is an interesting review of 8209 patients with PE. 3 most common finding that predict shock in PE patients are: Tachycardia, T wave inversion in V1, and ST elevation in aVR. They found six predictor in these patients: Tachycardia S1Q3T3 ST elevation aVR T wave inversion V1-V4 Complete RBBB Atrial Fibrilation Access to […]
Continue ReadingFAST-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 […]
Continue ReadingCervical Spine Clearance in Intoxicated patient!
We discussed this topic before in here, here, and here! JAMA published a prospective study with overall negative predictive value of 99.2% for patients with cspine injuries and a negative predictive value of 99.8% for ruling out cspine surgeris that required immobilization or stabilization. Link to article
Continue ReadingCOPD 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 […]
Continue ReadingTrimethoprim–Sulfamethoxazole or Placebo for skin Abscess
When we reviewed 3 previous studies here, here and here. We mentioned that should we really treat simple Skin abscess? NEJM published “Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess” in March 2016. Patients were randomised to TMP-SMZ 320-1600 mg twice a day for 7 days versus Placebo in patients greater than 12 years old with […]
Continue ReadingHeadache 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 […]
Continue ReadingPlatelet is not safe in Patient with Intracranial hemorrhage on anti platelet therapy
PATCH is a European based study that published in Lancet in May 2016. PATCH is trying to investigate the effects of platelet transfusion on acute intracranial bleed after using anti-platelet therapy. Study had 2 arms with 95 patients in each arm randomized to standard of care versus platelet transfusion in patient with intracranial bleed on anti […]
Continue ReadingClindamycin vs Trimethoprim-sulfamethoxazole for Wound Infection
We discussed this in 2015, but new study in Clinical Infectious Dis. again recommends antibiotic use in uncomplicated wound infection. They do not give an exact meaning of uncomplicated wound infection but we can say whenever physician meant to treat wound infection! This is a randomized, double-blind study at 5 US emergency departments. Patient received […]
Continue ReadingPrednisone 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 […]
Continue ReadingChest 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 […]
Continue ReadingHypoglycemia in the Treatment of HyperKalemia
Hypoglycemia in the treatment of hyperkalemia in ESRD frequently happens! There ae growing in the body of literature to address this issue with different recommendations: administering 25 g of dextrose with insulin and 25 g of dextrose 1 h after insulin based on our result that hypoglycemia occurred 1–3 h after insulin with dextrose. Link […]
Continue ReadingCOPD 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. […]
Continue ReadingEpinephrine, 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 […]
Continue ReadingAmiodarone, Lidocaine, or Placebo in OHCA
Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest, which one is your choice? The 2015 update of ACLS is still recommending Amio in Vfib, VTach Cardiac arrest after Shock and Epi, But new study in NEJM proved that among 3026 patients who randomized to Amiodarone (974), Lidocaine (993), or Placebo (1059), there were no statistically […]
Continue ReadingRisk stratification in patients with Pulmonary Embolism
CHEST journal Published a systematic review and meta analysis regarding Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT. In this review, in patients diagnosed with acute symptomatic PE, concomitant DVT was significantly associated with an increased risk of death within 30 days of PE diagnosis. Link […]
Continue ReadingBlood 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 […]
Continue ReadingNSAIDS 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 […]
Continue ReadingUnnecessary 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 […]
Continue ReadingAntibiotic’s Taste for your pediatric population!
This maybe an old study, but will give you a sense of what antibiotics will be less favorite for your patients. Among antibiotics Amxicillin and Cefixime have the best taste. Link to article
Continue ReadingGout 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 […]
Continue ReadingSepsis and Septic Shock, New Definition!
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 is the limitation of sensitivity and specificity of SIRS criteria, too much focus on inflammation cascade, and too many terms that really does not make […]
Continue ReadingReduce diagnostic Errors!
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 specifically for new Grad! Link to article
Continue ReadingContrast 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 […]
Continue ReadingNasal 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 […]
Continue ReadingUltrasound Guidance Facilitates Radial Artery Catheterization
Very happy to see US guided artery line is now in CHEST! Twelve trials used dynamic two-dimensional (2-D) ultrasound (N = 1,992). The study showed decreases first-attempt failure, mean attempts to success, mean time to success, and the occurrence of hematoma complications. Link to CHEST
Continue ReadingShoulder dislocation
There is a very good review of managing shoulder dislocation. It is not EBM, but worth to read.
Continue ReadingMigraine 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 […]
Continue ReadingStroke risk stratification in acute dizziness presentations!
Dizziness! one of the most complex and ambiguous term in ED. The first response: what do you mean? But sounds like we need to have more critical thinking than just a vertigo, or lightheartedness. Neurology in Nov.2015 Publishes an article regarding: Stroke risk stratification in acute dizziness presentations! There were 272 patients, 10.7% acute stroke […]
Continue ReadingVenous 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 […]
Continue ReadingC-Spine Clearance among children 5 years or younger
You can imagine how could be difficult to clear C-spin of 4 years old child after a MVC? Pretty scary! J Trauma Acute Care Surg published study that Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. This study was a a retrospective study among 2,972 preelementary trauma patients […]
Continue ReadingSeizure: 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 […]
Continue ReadingEKG 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 […]
Continue ReadingBenign Paroxysmal Positional Vertigo!
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 article
Continue ReadingChoice 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 […]
Continue ReadingBack 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 […]
Continue ReadingChecklist for Emergency Intubation in Trauma Patient
AEM published “A Preprocedural Checklist Improves the Safety of Emergency Department Intubation of Trauma Patients” in July. This is a prospective, pre-post intubation study on 141 trauma
Continue ReadingEBM, on unprovoked first seizure from Neurology!
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.
Continue ReadingCan we give carbapenems in patients with penicillins allergies?
You have a septic patient with PCN allergies! and now you are in trouble to start appropriate antibiotics due to cross reactivity. This is an Italian based study, that studied the cross-reactivity and
Continue ReadingSexually Transmitted Diseases Treatment Guidelines, 2015
New guideline by MMWR in June 2015, reviewing most important topics in STD. This guideline is very comprehensive and answers several critical questions regarding current and future therapy and focuses on STD.
Continue ReadingPE and Pregnancy
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?
Continue ReadingAppendicitis OR versus IV antibiotics!
I originally published this in 2015! I am revisiting this topic following the recent JAMA publication, which examined long-term outcomes over a 10-year period among patients treated with antibiotics. I found it particularly interesting to reflect on my own prior experience with this topic and to place those earlier observations in the context of the […]
Continue ReadingEndotracheal Intubation versus Supraglottic Airway in cardiac arrest
In a meta-analysis published in Resuscitation, 10 observational study reviewed and showed among patients with out of hospital cardiac arrest, patients who intubated via ETT had significantly better
Continue ReadingTo Stress or Not to Stress!
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
Continue ReadingAmiodarone with Dose of 300 mg!!!
I was reading an article regarding Managing Afib in Annals of EM. They are recommending Amiodarone 300 mg IV over an hour and then 10-50 mg/hour for 24 hour.
Continue ReadingControlling Afib/Aflutter with Underlying Diseases
Be careful, when you are trying to rate control your afib/aflutter patient. Using rate or rhythm control in patient with an acute underlying disease,
Continue ReadingHip Fracture, Xray negative, what’s next?
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,
Continue ReadingStroke, 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 […]
Continue ReadingPre-Oxygenation, Works or Does not Work!
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,
Continue ReadingJust 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.
Continue ReadingWhen will we STOP oral contrast?
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.
Continue ReadingAre 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 […]
Continue ReadingSIRS in Sepsis
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
Continue ReadingSurviving Sepsis Campaign update
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):
Continue ReadingLow Dose Ketamine for Analgesia
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.
Continue ReadingImportance of Vital Signs during Handoff
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
Continue ReadingPredictors of progress to septic shock among ED Patients
We were always told that Don’t underestimate triage or field vital signs! Now, we have a study that shows 25 % of patients presenting to ED with sepsis will progress to septic shock within 3 days.
Continue ReadingClindamycin Vs Bactrim foruncomplicated skin infections
NEJM published this article for antibiotic choice in uncomplicated skin infection. Patients were categorized as having cellulitis, abscess or both (if lesions of both cellulitis and abscess were present).
Continue ReadingClearance of suspected c-spine injuries in obtunded patient
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 […]
Continue ReadingSyncope Vs Near Syncope
This is my post in 2012, Annals of Emergency Medicine published a study this month regarding same topics.
Continue ReadingEvidence Base Medicine is a challenge in clinical practice!
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.
Continue ReadingHeadache After Trauma in Children
Another great PECARN study: Headache in Traumatic Brain Injuries From Blunt Head Trauma published in Pediatrics, Feb 2015.
Continue ReadingMigraine Headache: Prochlorperazine + diphenhydramine versus Metoclopramide + diphenhydramine
Pediatrics published an article regarding Migraine treatment in children. This is a retrospective study that has shown us non opioid medication has pretty significant effects in the treatment of Migraine.
Continue ReadingNew Drug for ACE-Inhibitor–Induced Angioedema!
NEJM published new treatment for ACEI-induced Angioedema. This study funded by Shire (a Biopharmaceuticals Company) and the Federal Ministry of Education and Research of Germany.
Continue ReadingHead CT for Syncope/Dizziness
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
Continue ReadingKetamine for Pain Relief
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
Continue ReadingWhen 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.
Continue ReadingProphylactic 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)
Continue ReadingACEP 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
Continue ReadingOxygen, 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?
Continue ReadingHow 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 […]
Continue ReadingSome 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
Continue ReadingSingle 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 […]
Continue ReadingEpinephrine 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 […]
Continue ReadingThershold 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:
Continue ReadingCavity 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
Continue ReadingAngioedema 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.
Continue ReadingSickle 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.
Continue ReadingMorphine 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,
Continue ReadingAlpha 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
Continue ReadingPEA 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,
Continue ReadingBlood 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
Continue ReadingBiphasic 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!
Continue ReadingCardiac 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
Continue ReadingStill 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
Continue ReadingEGDT 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 […]
Continue ReadingACEP 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:
Continue ReadingGlucagon 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? 😉
Continue ReadingINR 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.
Continue ReadingJNC 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).
Continue ReadingBlood 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 […]
Continue ReadingHeadache 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.
Continue ReadingDischarge 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 […]
Continue ReadingBronchitis; 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
Continue Reading