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. […]

Piperacillin/Tazobactam and Risk of Acute Kidney Injury with Vancomycin

By |Categories: Renal, Tox & Medications|

There are a few reasons why piperacillin/tazobactam (Zosyn) is not usually my first choice for a broad-spectrum gram-negative agent in the ED. First, at my institution, the Pseudomonas aeruginosa susceptibilities to pip-tazo are lower than that for cefepime. Second, pip-tazo does not have great CNS penetration, especially compared to ceftriaxone, cefepime, or even meropenem. Third, do we really need the anaerobic coverage that pip-tazo provides for every sick patient? Pip-tazo is great for empiric treatment of intra-abdominal and severe diabetic foot infections, but may not be needed for a hospital-acquired pneumonia. Fourth, with its frequent dosing (every 6 hours), too often the second dose is missed if the [...]

New Antibiotic Dalbavancin: Should we use this in the ED?

By |Categories: Tox & Medications|

A new antibiotic will soon be approved for skin and soft tissue infections (SSTIs): dalbavancin. The company behind the drug will likely begin marketing heavily to emergency physicians as many patients with SSTIs seek care in the Emergency Department (ED). However, should we seriously consider dalbavancin as an addition to an ED’s arsenal against SSTIs and should it change our practice? […]

Geriatric Emergency Departments: Coming to a Hospital Near You?

By |Categories: Expert Peer Reviewed (Clinical), Geriatrics|

We are all familiar with the concept of pediatric EDs. We see them as medical students, we train in them as residents, and we work alongside pediatric EM fellows. It is generally clear what pediatric EDs have to offer: smaller sized beds and equipment, nurses trained in pediatric triage and assessment who know how to put IVs in babies and calm crying kids, and physicians with training in pediatric Emergency Medicine. But what about the other end of the age spectrum? Over the last 10 years geriatric EDs, also called Senior EDs, have been popping up around the country. You [...]

Deep Vein Thrombosis (DVT): Wells criteria and D-dimers happy together

By |Categories: Cardiovascular|Tags: |

You are evaluating a 45-year-old male who is complaining of calf pain. He has a history of cancer however he has never had a clot in the past.   The leg is neither swollen nor warm but he notes a cramping sensation in the posterior portion of his calf.  You are concerned for a deep vein thrombosis (DVT) and consider the multiple means to reliable exclude the diagnosis: Wells score, D-dimers, ultrasound? What works? […]

Atypical Antipsychotic Medication Re-initiation in the Emergency Department

By |Categories: Psychiatry, Tox & Medications|

The acute episode of intoxication and agitation has subsided and your patient is calm. She has been medically cleared and is ready to be moved to a less acute, less monitored portion of the ED to await further assessment and treatment for her underlying psychiatric conditions. As a well-intentioned emergency medicine practitioner, you wish to give your patient the tools she needs to maintain this calm status by restarting her home atypical antipsychotic medication. What is the best way to go about doing this? […]

Trick of the Trade: Making your own homemade ultrasound gel

By |Categories: Expert Peer Reviewed (Clinical), Tricks of the Trade, Ultrasound|

You are spending a month in rural Kenya, doing an ultrasound teaching course. Your enthusiastic participants have been ultrasounding every chance they get. Unfortunately, this has caused your ultrasound gel supplies to dwindle. It will be a month before a new shipment of gel arrives from Nairobi. This gel will cost about $5 per bottle, which is a considerable expense for the local hospital’s budget. […]

Understanding Phenytoin Equivalents

By |Categories: Tox & Medications|

Sometimes, in an effort to make things simpler, we actually make them more confusing. Such is the case with phenytoin equivalents.  Fosphenytoin is a water-soluble prodrug of phenytoin. After IV administration, much of the fosphenytoin is metabolized to phenytoin within 15 minutes. Advantages over phenytoin include the option for IM administration and less cardiotoxicity allowing for faster infusion rates. Even the potential for hyperphosphatemia from the release of phosphate is generally inconsequential.  […]

Neuraminidase Inhibitors for Influenza – The Truth, The Whole Truth, and Nothing But the Truth Finally

By |Categories: Infectious Disease, Tox & Medications|

Over the last 5 years, the use of neuraminidase inhibitors for the treatment of influenza has skyrocketed. Emergency physicians have been pushed to prescribe these medications under the belief that they reduced symptoms, the risk of complications, hospitalizations, and transmission. However, the recommendation for the use of these drugs has never sat on firm evidence-based ground. So what did we know then, and what do we know now? […]

PEITHO Trial: Fibrinolysis for Intermediate-Risk Pulmonary Embolism

By |Categories: Cardiovascular, Expert Peer Reviewed (Clinical), Pulmonary|Tags: |

Most of us would agree that massive PE is treated with fibrinolysis and non-massive PE is treated with anticoagulation. The area of great debate has been the optimal treatment for sub-massive PE. The MOPETT Trial was published in January 2013 and although the patient population was small, it did show a huge benefit in pulmonary pressures at 28 months with fibrinolysis. The next study we have all been waiting for is the Pulmonary Embolism Thrombolysis (PEITHO) trial, which was just published yesterday in the NEJM, evaluating fibrinolysis for patients with intermediate-risk PE. […]