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 ReadingOne 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 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 ReadingWe 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 ReadingIt 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 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 ReadingCHEST 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 ReadingThere 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 ReadingWhat 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 ReadingI 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 ReadingThis 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 ReadingAnnals 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 ReadingJAMA 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 ReadingFound 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 ReadingIs 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 ReadingIf 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 ReadingVery 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 ReadingThere is a very good review of managing shoulder dislocation. It is not EBM, but worth to read.
Continue ReadingI 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 ReadingDizziness! 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 ReadingWe 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 ReadingThere 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 ReadingI 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 ReadingNeurologic 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 ReadingSounds 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 ReadingWe 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 ReadingAEM 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 ReadingEvidence-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 ReadingYou 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 ReadingNew 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 ReadingHaving 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 ReadingI 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 ReadingIn 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 ReadingTroponin 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 ReadingI 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 ReadingBe 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 ReadingI 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 ReadingRecent 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 ReadingJust 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 ReadingI 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 ReadingYou 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 ReadingThe 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 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 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 ReadingWhen 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 ReadingWell, 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 ReadingWe 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 ReadingNEJM 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 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 ReadingThis is my post in 2012, Annals of Emergency Medicine published a study this month regarding same topics.
Continue ReadingI 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 ReadingAnother great PECARN study: Headache in Traumatic Brain Injuries From Blunt Head Trauma published in Pediatrics, Feb 2015.
Continue ReadingPediatrics 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 ReadingNEJM 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 ReadingAnother 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 ReadingI 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 ReadingCleveland Clinic Journal of Medicine has a nice review on Rib Fracture and an algorithm to approach rib fracture.
Continue ReadingAre Prophylactic Antibiotics Necessary for Anterior Nasal Packing in Epistaxis? There are some discussion regarding toxic shock syndrome and infections(otitis media, sinusitis)
Continue ReadingIn 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! 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 ReadingIt 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 ReadingIt 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 ReadingThis 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 ReadingWe 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 ReadingIn 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 ReadingVery 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 ReadingWe 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 ReadingI 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 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 (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 ReadingMedical 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 ReadingI 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 ReadingWe 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 ReadingThis 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 ReadingNEJM 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 ReadingNEJM 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 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 ReadingThis 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 ReadingFrom 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 ReadingAfter 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 ReadingAs 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 ReadingAmerican 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 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 ReadingDilemma: 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 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 ReadingJAMA 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 ReadingEpmonthly had a very nice review with a mini board review perspective, regarding common complications of shoulder dislocation and reduction.
Continue ReadingWe 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 ReadingPain 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 ReadingI 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 ReadingMMWR in latest Grand round section discussed the options for gonorrhea treatment and their recommendation in case of cephalosporin allergy,
Continue Readingand 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 ReadingThere 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 ReadingThis 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 ReadingAm 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 ReadingJACC 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 ReadingWhat 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 ReadingThat 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 ReadingTIA 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 ReadingWhat 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)
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