Dilaudid (Hydromorphone), How much?
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.
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Lumbar Puncture
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
Continue ReadingPCN resistant Gonorrhea
MMWR in latest Grand round section discussed the options for gonorrhea treatment and their recommendation in case of cephalosporin allergy,
Continue ReadingOral Contrast and LOS
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
Continue ReadingKetorolac in the Treatment of Acute Migraine: A Systematic Review
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:
Continue ReadingChallenges regarding Troponin
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.
Continue ReadingCO Poisoning, New pracice guideline
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:
Continue ReadingaVR: The most Ignored Lead
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
Continue ReadingTypical Vs Atypical Chest pain
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
Continue ReadingCONTRAST CT or NON CON CT?
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 […]
Continue ReadingTransient Ischemic Attack
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%).
Continue ReadingHypertension treatment
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)
Continue ReadingCardiac Arrest Survival Is Rare without Prehospital Return of Spontaneous Circulation
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
Continue ReadingEarly Administration of Systemic Corticosteroids in Children With Asthma Exacerbation
July 2012: Annals of Emergency Medicine: Early Administration of Systemic Corticosteroids Reduces
Continue ReadingComplications Associated with Sickle Cell Trait
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, […]
Continue ReadingEKG differentiation of early Repol vs STEMI
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!!!
Continue ReadingSYNCOPE vs Near SYNCOPE
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 […]
Continue ReadingLow Back Pain
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
Continue ReadingNew Concepts in the Assessment of Syncope
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 […]
Continue ReadingWhat is the role of Morphine in Flash Pulmonary Edema?
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.
Continue ReadingStandards of Medical Care in Diabetes: 2012
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
Continue ReadingComparison of arterial blood gas vs. venous blood gas
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.
Continue ReadingPrehospital Epinephrine Use and SurvivalAmong Patients With Out-of-Hospital Cardiac Arrest
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.
Continue ReadingPan-Scan for detection of injuries in patients with major blunt trauma
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 […]
Continue ReadingClindamycin or Bactrim for pediatric skin and soft-tissue infections
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.
Continue ReadingGuidelines for the Assessment and Management of Anaphylaxis
I am teaching this topic to medical students, interns, and residents every month and I found this valuable guideline by World Allergy Organization.
Continue ReadingIntramuscular versus Intravenous Therapy for Prehospital Status Epilepticus
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.
Continue ReadingNormalization of Vital Signs Does Not Reduce the Probability of Acute Pulmonary Embolism
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.
Continue ReadingHyperglycemia in Hospitalized Patients, An Endocrine Society Clinical Practice Guideline
The Journal of Clinical Endocrinology & Metabolism published a practice guideline in Jan.2012. Focus of this guideline is management of hyperglycemia in
Continue ReadingEffective Antibiotic Treatment Prescribed by Emergency Physicians in Severe Sepsis or Septic Shock
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.
Continue ReadingCardiac arrest and prognosis
This is one of the challenging topics in EM. when should you stop CPR? what parameters do you have to continue versus terminate CPR?
Continue ReadingCervical Spine MRI in Alert, Neurologically Intact Trauma Patients
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.
Continue ReadingPrediction of Pneumonia in a Pediatric Emergency Department
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.
Continue ReadingEmergency Hospitalizations for Adverse Drug Events
To estimate the frequency and rates of hospitalization after emergency department visits for adverse drug events in older adults between 2007-2009.
Continue ReadingActual or the corrected serum sodium in DKA!
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
Continue ReadingMRSA Therapy! New Guideline
IDSA (Infectious Diseases Society of America) published a new guideline this year for treatment of soft tissue infections and MRSA.
Continue ReadingCO Poisoning
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:
Continue ReadingChildren at very low risk of TBI per PEACRN
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.
Continue ReadingPediatric UTI; Practice guideline from AAP
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
Continue ReadingAre arterial and venous samples clinically equivalent….
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 […]
Continue ReadingEffect of adrenaline on survival in out-of-hospital cardiac arrest
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
Continue ReadingVolume Status in Septic Shock
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
Continue ReadingTop Ten Mistakes in Residency
Top Ten Mistakes in Residency by: Peter Deblieux
Continue ReadingDiagnostic Accuracy of VBG in DKA
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 […]
Continue ReadingTop Ten Documentation Mistakes
ACEP’s Video presentation of Dr. Greg Henry and Dr. Gillian Schmitz discussing the top ten documentation mistakes.
Continue ReadingEmergency Medicine Past and Future
Emergency-Medicine-Past-and-Future by: Peter Rosen
Continue ReadingFast Track
How to do Lung Ultrasound to rule out Pneumothorax! 1. Select your probe: Linear probe, or vascular probe with low penetration and high frequency.
Continue ReadingWhich Anti-emetic for Undifferentiated Vomiting
Which Anti-emetic for Undifferentiated Vomiting By: Ingrid Lim
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