Low 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 ReadingCategory: PGY4
Importance 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 ReadingWhat is the optimal dose of Ketorolac as pain medication?
What evidence does exist regarding dosage of Ketolorac? Our practice is usually 60 mg IM and 30 mg IV, but interesting review by Medscape showed may be this is not a right dose.
Continue ReadingWorsening Trends in the Management and Treatment of Back Pain
JAMA published an article emphasizing our EM textbooks highlights regarding the simple treatment of MSK back pain are NSAIDS and Acetaminophen and then muscle relaxant.
Continue ReadingShoulder Dislocation and complications
Epmonthly had a very nice review with a mini board review perspective, regarding common complications of shoulder dislocation and reduction.
Continue ReadingShort-term vs conventional glucocorticoid therapy in acute exacerbations of COPD
We are practicing short term of Steroid in management of asthma and COPD in ED, But this is very nice to hear from our colleagues to prove our practice. JAMA, in June 2013 published an article with concept of short term prednisone for 5 days is not inferior to
Continue ReadingDilaudid (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.
Continue ReadingLumbar 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 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 ReadingLung ultrasound in critically ill patients
Lung ultrasound in critically ill patients: Comparison with bedside chest radiography. This study was done in Greece and their finding is in general ICU population lung ultrasound
Continue ReadingWhich Anti-emetic for Undifferentiated Vomiting
Which Anti-emetic for Undifferentiated Vomiting By: Ingrid Lim
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