Cyclobenzaprine vs TCA Toxicity

By |Categories: Tox & Medications|

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? […]

When the PERC Rule Fails

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

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? […]

AMA: 2 high risk myths and misconceptions

By |Categories: Medicolegal|Tags: |

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.   […]

BISAP, EHMRG, ORT: 3 New Medical Scores You’ve Never Heard Of

By |Categories: Cardiovascular, Gastrointestinal, Tox & Medications|

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? […]

Blood Pressure Management in Adults (JNC 8 and ACEP Policy)

By |Categories: Cardiovascular|

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: Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Does treatment with antihypertensive pharmacologic [...]

Serotonin Syndrome: Consider in the Older Patient with Altered Mental Status

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

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. […]

Is Pelvic Exam in the Emergency Department Useful?

By |Categories: Ob/Gyn|

Women with undifferentiated abdominal pain and/or vaginal bleeding commonly present to the emergency department. Many textbooks advocate for the pelvic exam as an essential part of the history and physical exam. Performance of the pelvic exam is time consuming to the physician and uncomfortable for the patient. It is with great regularity that emergency physicians make clinical decisions, based on information derived from the pelvic examination, but is this information reliable and does it effect the clinical plan of patients? […]

Highland Emergency Ultrasound website: Check it out

By |Categories: Social Media & Tech, Ultrasound|

Need a quick refresher course on how to do an ultrasound-guided ear block or ankle arthrocentesis? I recently found out about Drs. Andrew Herring and Arun Nagdev’s Highland Emergency Ultrasound website and thought it was a great resource to share with others in the EM world. The website has easy-to-follow pictorial instructions of anatomic landmarks, probe placement, and ultrasound images of the most common blocks and other procedures. […]

“Is there a doctor on-board?” 5 tips for dealing with in-flight emergencies

By |Categories: Medicolegal|Tags: |

On average, in-flight medical emergencies occur about 15 times per day. When asked by flight crews to help in a medical emergency, providers have fairly extensive legal protection, and in some cases have a legal obligation to help [1]. In the U.S., all 50 states have some form of a “good Samaritan” law, which provides legal protection to medical providers who perform their services in response to medical emergencies outside the hospital. While these laws typically apply broadly to most out of hospital emergencies, in 1998 Congress specifically passed the Aviation Medical Assistance Act (AMAA) which offers legal protection to providers, [...]