As emergency physicians, we are experts in pain control. We frequently write opiate prescriptions for patients being discharged home. Unfortunately, an occasional patient tries to forge my prescription. At times, I get a call from pharmacy for prescriptions that were suspiciously written. For instance several years ago, I had someone try to forge 100 tablets of “Mophine”.
In the Emergency Department, we often order urine toxicology screens for patients with altered mental status without an obvious cause. I find that patients are often rather forthcoming about their drug use, if they are alert enough to talk. In those cases, ordering a urine toxicology screen is unnecessary.
When you do order a tox screen, however, how do you interpret the information? While the result is a binary answer (positive vs negative), there are some nuances to interpretation. For instance, how long does a patient with urine toxicology remain positive for the drugs? Are there any medications that can cause false positives? See the helpful table below from a great review article in American Family Physician.
Check out what your laboratory screens for and, more importantly, what it does NOT screen for. Our lab, for example, does not screen for PCP but does screen for MDMA (ecstacy). That isn’t a big deal, since patients who ingest PCP aren’t too hard to detect clinically. They have crazy vertical nystagmus, and often there are at least 6 police officers trying to restrain the yelling patient.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications.
Go to ALiEM (PV) Cards for more resources.
The treatment of shock should focus on correcting the underlying pathophysiology. With persistent hemodynamic instability, a vasopressor and/or inotrope should be selected. Reviewing receptor physiology can help you select the best-fit agent for the patient’s clinical condition. There is an especially useful table on medication selection in the reviewed 2008 EM Clinics of North America article.
This installment of the Paucis Verbis (In a Few Words) e-card series reviews Vasopressors and Inotropes for the Treatment of Shock.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Edit 3/28/14: Dopamine removed as second-tier agent for septic shock (mainly reserved for rare cases of inappropriate bradycardia at low risk for arrhythmias)
Updated on 6/1/13: Old PV card revised to reflect the 2012 ACCP guidelines
With recent discussion about the potential closing of California Poison Control Centers due to budget cuts, I suddenly became shockingly aware of how much Emergency Departments depend on these centers for assistance. They are always so knowledgeable and helpful in managing various ingestions and poisonings.
Given all the recent brouhaha around propofol and Michael Jackson, I thought I would review the 2007 Annals of EM Clinical Practice Advisory paper on the use of propofol in the Emergency Department for procedural sedation. This is one of the 2009 Lifelong Learning Self-Assessment (LLSA) articles. Each year EM-board certified physicians are tested on 20 pre-selected LLSA articles to maintain eligibility for re-certification.