Fiona is a 6 year old female who presents to your emergency department after falling onto her left hand while racing on the playground. X-ray of the left upper extremity reveals a distal radius fracture with minimal displacement and angulation. You plan to place her arm in a splint and arrange for close orthopedic follow-up. The only problem: Fiona is in a lot of pain, especially with any manipulation of her arm, and Dad is worried that she will not be able to tolerate having a splint placed. You consider reaching for an intranasal medication to help Fiona feel more comfortable and to place the splint in a quick, efficient manner.
The 2016 American Headache Society (AHS) released recommendations on managing adults with acute migraine headaches.1 In the November 2017 EM:RAP LIN Sessions podcast episode that I recorded, I realized that I overgeneralized several statements about anti-dopaminergic agents and the use of concurrent diphenhydramine for akathisia risk reduction. So I wanted to clarify things and share a deeper-dive on the topic, thanks to the constructive feedback and help of headache guru Dr. David Vinson and EM pharmacists Dr. Curtis Geier, Dr. Bryan Hayes, and Dr. Zlatan Coralic. Below summarizes the nuanced thought processes in the anti-dopaminergic treatment of migraines.
The above question is common from patients with a history of an allergic reaction seen for a repeat emergency department visit. The manufacturers of EpiPen caution not to use the pen beyond the expiration date, and if the drug solution becomes discolored (oxidation). But EpiPens are expensive! Is there harm in using the pen beyond the expiration date? What should we tell our patients?1
Paraphimosis occurs when a retracted foreskin can’t be reduced back over the glans of the penis. Risk factors for paraphimosis include scarring, vigorous sexual activity, chronic balanoposthitis, and forgetting to replace the foreskin after catheterization or manipulation.
Paraphimosis can be a urological emergency as the tight ring formed by the foreskin can cause ischemia to the tip of the penis and eventually gangrene. Timely reduction is of high importance. Treatment involves gentle compression of the glans and gradual manual foreskin retraction.1 Unfortunately, as time goes on, more swelling occurs making traditional reduction techniques more difficult.
You are working your evening shift at the pediatrics emergency department, and you walk into a darkened patient room with a distressed mother and her otherwise healthy 10-year old son who is curled in a ball, holding his head and crying. Her mother tells you that the around-the-clock ibuprofen has barely touched his 2-day headache.
After determining that your patient has no neurologic deficits and that this is most likely a primary headache, what can you do to break his symptoms?
Prochlorperazine is a commonly used medication in EM. In certain patients prochlorperazine does wonders for migraines, and remains a great antiemetic choice for undifferentiated nausea/vomiting when ondansetron is ineffective. However, prochlorperazine has antidopinamergic activity increasing the chances of extrapyramidal symptoms (EPS), such as akathisia, dystonia, parkinsonism, and rarely tardive dyskinesia. A common practice in the ED is to give diphenhydramine with prochlorperazine to attenuate EPS. Does this really work? What is the evidence?