Top 10 reasons NOT to order a CT scan for suspected renal colic

By |Categories: Expert Peer Reviewed (Clinical), Genitourinary, Radiology|

It appears that the excitement and utilization of computed tomography (CT) imaging in the emergency department (ED) has far outpaced our concern for the short- and long-term consequences of increased reliance on this technology. CT has greatly supplemented, or even replaced, our clinical decision making for many chief complaints.  Many articles document the dramatic increased CT use in contemporary practice, including a 330% increase in the rate of CT imaging from 1996 to 2007. The likelihood of a CT order being part of any ED encounter now approaches 15%, with no signs of decline.1 […]

Article: Hypotonic maintenance IV fluids in pediatrics

By |Categories: Endocrine-Metabolic, Pediatrics|Tags: |

A 6-month-old male presents to the emergency department with diarrhea and vomiting. Despite antiemetic therapy, the the child is unable to tolerate oral intake in the ED and so you opt to admit him to the hospital for IV fluids.  The pediatric hospitalist requests that you write maintenance fluids prior to admission to the floor. Utilizing the 4-2-1 rule you calculate maintenance needs and choose D5 ½NS as your fluid. This is what you had been taught to utilize in children. It seems appropriate… but is it? […]

Beware of fluoroquinolones: You, your patient, and the FDA

By |Categories: Medicolegal, Tox & Medications|Tags: |

Fluoroquinolones are a widely used class of antibiotic that are effective in treating a wide variety of infections. Despite their popularity there is increasing concern regarding to the potential complications associated with these agents. In 2008, the U.S. Food and Drug Administration (FDA) issued a black box warning involving fluoroquinolone use and an increased risk of tendon rupture. More recently in 2013 the FDA released another warning regarding the risk of peripheral neuropathy and required additional warnings to be added to the drug labels [1]. […]

High Sensitivity Troponin T and Acute Myocardial Infarction: One and Done?

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

There has been a lot of publicity about evaluation of chest pain patients in the emergency department (ED) with high sensitivity troponin testing. In the past with older troponin assays, clinicians would evaluate patients, get an ECG, and an initial set of cardiac biomarkers. The subsequent set of biomarkers would be performed at 6-8 hours later before determination of disposition. In the past few years, several studies have been published evaluating point of care troponins,  sensitive troponins, and high sensitivity troponins which have changed our practice and evaluation of these patients.  An early version of a study was recently released [...]

Uncomplicated Urinary Tract Infections in Older Adults: Diagnosis and Treatment (Part 2)

By |Categories: Genitourinary, Geriatrics|

It seems like a simple enough question: How do you diagnose and treat uncomplicated urinary tract infections (UTIs) in older adults? The answer is: It depends. In Part 1 of this post we discussed the diagnosis of UTIs in cognitively intact older adults and those with underlying cognitive impairment. This post will discuss treatment options. […]

Cellulitis: Do Not Get Blood Cultures

By |Categories: Dermatology, Expert Peer Reviewed (Clinical), Infectious Disease|

You are treating a patient with left lower leg cellulitis. The nurse is going to establish IV access, draw blood work, and give analgesia and antibiotics. Before walking into the room, the nurse asks, “Do you need me to grab a set of blood cultures?” Additionally the hospitalist had asked you to order a “set of cultures” on your most recent cellulitis admission. Should you proceed? […]

Trick of the Trade: Nasal foreign body removal using foley catheter

By |Categories: ENT, Tricks of the Trade|

    A healthy 4 year-old boy is brought in by mom for a plastic bead up his nose. The mom states, “The last time the other doctors had to be called, and it took forever. Oh, and I have to pick up his brother from school in 30 minutes. Can you get it out, doc?” The patient is squirming even as you take a quick peek at his nose, but you catch a glimmer of the bead up his right nare. […]

ALiEM-Annals of EM Journal Club: Targeted Temperature Management

By |Categories: Critical Care/ Resus, Journal Club|Tags: |

We are very excited this month to bring you our third Global Journal Club. We hope you will participate in an online discussion based on the clinical vignette and questions below from now until March 27th. Respond by commenting below or tweeting (#ALiEMJC). On Tuesday, March 25, 2014 at 1630 EST, we will be hosting a 30-minute live Google Hangout with Dr. Niklas Nielsen, the lead author of the Targeted Temperature Management (TTM) study, that is informed by the discussion. Later this year a summary of this journal club will be published in Annals of Emergency Medicine. […]

Trick of the Trade: Parting the hair for scalp laceration repair

By |Categories: Trauma, Tricks of the Trade|

Trying to suture or staple a scalp laceration is oftentimes a hairy proposition for emergency physicians who repair these types of wounds regularly. Although the “hair apposition technique” method is one option, if one opts for sutures or staples, the most difficult part of the procedure is trying to avoid trapping hair strands within the wound, which may cause wound dehiscense, a foreign body reaction, or a local infection.  […]

ProCESS Study: Identify sepsis early and treat aggressively

By |Categories: Infectious Disease|Tags: |

Today, the New England Journal of Medicine just released a landmark paper by the ProCESS (Protocolized Care for Early Septic Shock) trial investigators. There has already been much buzz about this on various blogs and websites, including St. Emlyn’s, MedPageToday, and MDAware. I received an email from my colleague Dr. Michael Callaham, who shared some direct comments and pearls from Dr. Donald Yealy, (professor and chair of emergency medicine from the University of Pittsburgh Medical Center) who was the first author of this writing team. Thank you to Dr. Yealy for allowing me to share your team’s comments with the ALiEM readership. [...]