Anxiolytics and Hypnotics: Are They Doing Harm?

By |Categories: Psychiatry, Tox & Medications|

A patient presents to the emergency department complaining of increasing insomnia due to anxiety. She states that she is not actively suicidal nor homicidal but she has trouble “turning off her brain” at night in order to sleep and her insomnia is worsening her anxiety. She has a history of morbid obesity and smokes 1 pack of cigarettes per day. In order to help you consider writing her a prescription for 5 mg of zolpidem as you presume it to be a benign way to deal with her current sleep disorder. But what does the evidence say about these drugs [...]

tPA Administration: Don’t Forget the Leftover Volume in the Pump Tubing

By |Categories: Tox & Medications|

Whether alteplase (tPA) is given for ischemic stroke, pulmonary embolism, or STEMI, there is an important practical issue to be aware of during administration. Dr. Charles Bruen (@resusreview) published a great step-by-step pictorial tPA Mixing Tutorial. Once the tPA is mixed, it will invariably be infused via a smart pump through its corresponding tubing. At my institution we use Alaris® CareFusion smart pumps, through the principle applies irrespective of which brand pump is used. […]

PV Card: Local anesthetic toxicity calculations

By |Categories: ALiEM Cards, Expert Peer Reviewed (Clinical), Pre Publication Critique (Clinical), Tox & Medications|

Local anesthetics (LAs) are widely employed to achieve tissue infiltration, peripheral and regional anesthesia, and neuraxial blockades. Despite their well-established toxic dose limits, these agents continue to pose a substantial risk of morbidity and mortality due to local anesthetic toxicity and overdose. […]

High risk back pain: Cauda Equina Syndrome (EREM)

By |Categories: Medicolegal, Orthopedic|Tags: |

Cauda equina syndrome (CES), which occurs due to compression of the distal lumbar and sacral nerve roots, is a potentially devastating cause of back pain. CES is often missed on the patient’s initial visit which can lead to  significant neurologic compromise in a matter of hours [1]. To improve patient outcomes and minimize medicolegal risk, providers need to understand the limitations of the history and physical and carefully consider the diagnosis of CES in any patient with back pain. […]

Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers?

By |Categories: Cardiovascular, Tox & Medications|

Rate control with IV medications is recommended for atrial fibrillation in the acute setting in patients without preexcitation. This was a Class 1 recommendation (Level of Evidence B) per the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation [1]. What does the evidence say? Are calcium channel blockers or beta blockers better? […]

Simulation Trick of the Trade: Bleeding Cricothyroidotomy Model

By |Categories: Medical Education, Simulation, Tricks of the Trade|Tags: |

One advantage of simulation as an educational tool is the re-creation of cognitive and emotional stresses in caring for patients. Doing this for a high fidelity scenario is relatively easy – add additional patients, make a them loud, combative, or otherwise cantankerous, and add interruptions for good measure. However, when training for procedures in the simulation lab, we practice the procedure in isolation on a “task trainer” without cognitive and emotional stress for context. An off-the-shelf task trainer can do a superb job of teaching the mechanics of performing a procedure, but they lack complexity necessary to train for performing the procedure under stress. […]

Transitions of Care: Top 10 things admitting providers wish we did for older adults

By |Categories: Geriatrics|

“Transitions of care” has become a hot topic in the care of older adults. It is usually applied to the transition from the hospital to home or the hospital to a nursing facility. But what about the transition from the ED to an inpatient service? It turns out there are plenty of things we could be doing (or not doing) to help smooth that transition and improve patient care. Here are some thoughts from admitting physicians with geriatrics training. […]

Trick of the Trade: Nail Bed Repair With Tissue Adhesive Glue

By |Categories: Trauma, Tricks of the Trade|

Patients with fingertip injuries involving the nail bed typically present to the emergency department and require meticulous repair of the nail bed to prevent long-term cosmetic and functional disability. There are several methods to repair nail beds, typically involving absorbable suture, but maybe there is a faster way with similar cosmetic and functional outcomes.  […]

Ondansetron: Has it reduced need for IV rehydration in vomiting kids?

By |Categories: Gastrointestinal, Pediatrics|Tags: |

A 3-year-old male presents to the emergency department (ED) complaining of vomiting and diarrhea that has been occurring for 2 days. The mother states that the child has had fewer wet diapers today but has made tears when crying. On physical examination you note no rebound or guarding of the abdomen and determine that the child is moderately dehydrated. Your initial plan is to administer ondansetron and rehydrate the child orally. This is what you have been taught but is it actually efficacious? A just published 2014 JAMA Pediatrics article attempted to answer this question. […]