Should we treat a cyclobenzaprine (Flexeril) overdose similar to a tricyclic antidepressant (TCA) overdose? With the only difference between the commonly prescribed muscle relaxant, cyclobenzaprine, and the TCA amitriptyline consisting of a single double bond, should the emergency provider be concerned for life threatening arrhythmias in cyclobenzaprine overdose?
Kline et al developed a clinical decision tool based on parameters that could be obtained from a brief initial assessment to reasonably exclude the diagnosis of pulmonary embolism (PE) without the use of D-dimer in order to prevent unnecessary cost and the use of medical resources. 1 Many of us have used the Pulmonary Embolism Rule-out Criteria (PERC) rule by now, but we should be clear on what it includes. Are we using it appropriately?
Patients who leave the emergency department against medical advice (AMA) are at an increased risk of having a bad medical outcome, and can be a source of significant medicolegal risk to providers. Earlier we reviewed eight elements to address when signing a patient out AMA. There are two common myths regarding patients who leave AMA that can complicate an already difficult situation.
Let’s face it. You’ve heard about the A-a gradient. And free water deficit. And even the APACHE-II score. But how useful are these in your daily practice? You don’t care that much if a patient has shunt physiology in the first case, nor exactly how much free water they’re lacking in the second. And in the third case, your clinical acumen is probably pretty good at predicting a sick patient’s mortality already. But what about the new medical scores of BISAP, EHMRG, and ORT?
Hypertension is one of the most common conditions seen in primary care clinics and emergency departments (EDs). Frequently, patients are found to have asymptomatic hypertension and referred to EDs for management, despite the fact that rapidly lowering blood pressure is not necessary and may be harmful. Yet many clinics still refer these patients for emergent management. In December 2013, the Eighth Joint National Committee (JNC 8) published a new, open-access, evidence-based hypertension guideline in JAMA. They only cited randomized clinical control trials to answer three questions:
Acute pain management in the ED is challenging. For patients on buprenorphine, it can be even more difficult. What if a patient on buprenorphine presents to the ED with a painful condition that requires a short course of opioid therapy?
What’s the first thing that pops into your head when you see an older woman presenting to the ED from a nursing facility with atraumatic altered mental status? If you’re like me, ‘UTI’ comes quickly to mind. I then banish the thought of a UTI and force myself to go through a worst-first differential diagnosis to exclude, either through the history and clinical assessment or through testing, more dangerous causes. This is a case of a 67-year-old woman with an unusual cause of altered mental status… and a UTI.