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    We determine whether omitting the pelvic examination in emergency department (ED) evaluation of vaginal bleeding or lower abdominal pain in ultrasonographically confirmed early intrauterine pregnancy is equivalent to performing the examination. [...]

    The search identified 4,832 references; 14 trials evaluating 18 instruments met inclusion criteria. None of the trials with a focus on psychometric analyses met criteria for reliability, validity, or usability, and none of the diagnostic and cohort studies were at low risk of bias in all domains of QUADAS-2 (ie, there were no high-quality studies). [...]

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    You are doing CPR wrong EMCrit by Scott Weingart. [...]

    The ketamine-tolerant patient presents a quandary to clinicians who aren't familiar with this phenomenon.  The first time I encountered this, I was baffled and aborted the procedure after giving 200 mg ketamine.  Eventually I realized that the drug isn't "failing" to work, but rather we are failing to administer a sufficiently high dose.  EMCrit by Josh Farkas. [...]

    Effective, rapid peer review allows for the creation of a new series of posts.  These posts will cover material which isn't supported by much evidence nor experience.  In the past, I wouldn't have felt comfortable posting this material to the blog.  EMCrit by Josh Farkas. [...]

    Acid Test your Resus EMCrit by Scott Weingart. [...]

    A critical review of the EGDT study EMCrit by Paul Marik. [...]

    The next in the microskill series EMCrit by Scott Weingart. [...]

    A recent publication in the NEJM by Hofmann et al (1) serves as a nice reminder that so many of our therapeutic staples while based on sound physiological reasoning fail to translate into clinically important realities when empirically tested. This mammoth undertaking, entitled the DETO2X trial, randomized 6629 adult patients (>30 years old) presenting to […] EMCrit by Rory Spiegel. [...]

    As with many uncommon situations that are unique to critical illness, we cannot always rely on specialist consultation.  Critical care practitioners must develop a firm grasp of this diagnosis.  This post will explore some diagnostic conundrums in brain death diagnosis.  The radionuclide flow scan is emphasized because it is the most commonly used tool to sort out difficult cases. EMCrit by Josh Farkas. [...]

      Never has a biomarker with so much evidence demonstrating its disutility, enjoyed such a long reign of prosperity as BNP and its natriuretic analogs. And while evidence discrediting BNP’s use for the diagnosis and inpatient management of acute exacerbations of heart failure (HF) is well documented, its utility to guide outpatient therapy in patients […] EMCrit by Rory Spiegel. [...]

    ApOx & PreOx Update EMCrit by Scott Weingart. [...] Conquering Night Shifts and Soft Tissue Ultrasound with Mike Mallin Mike Mallin is a legend in emergency ultrasound but, by day, he’s a regular guy and community ED doc. In this episode, Mike and Rob talk about making the change from an academic to community medicine job working in a place that sparks joy working locum tenens soft tissue ultrasound looking for abscess placing peripheral […] - Emergency medicine podcasts, reviews and curbside consults [...] Getting Sued This is not an easy episode. It’s not easy because a doctor gets named in a lawsuit, a patient has a bad outcome, and it openly discusses some of the systems failures we have in medicine. If that’s enough to turn you off, close the page and go about your day. You’ll probably be happier […] - Emergency medicine podcasts, reviews and curbside consults [...] Peeing Blood and the Pesky Erection Emergency management of priapism, hematuria, and interstitial cystitis are discussed with urologist Brian Shaffer. Warning: the following program contains graphic descriptions of medical procedures. Listener discretion is advised. Direct Download Stuff Adam and Rob have discovered recently and are really digging Rob Dermastent Bounce Bars esp the Cacao Mint. Super tasty and efficient nutrition balls […] - Emergency medicine podcasts, reviews and curbside consults [...] When Breath Becomes Air. Lucy Kalanithi Interview Last summer I took a road trip to Canada and during the drive I listened to the book When Breath Becomes Air. That was a year ago, and I still think about that book, almost daily. When Breath Becomes Air is the autobiographical account of the final 2 years of neurosurgeon Paul Kalanithi life. Paul […] - Emergency medicine podcasts, reviews and curbside consults [...] Spring 2017 Journal Club It may be summer (in the northern hemisphere), but that doesn’t mean we can talk all the goodness that was our spring journal club. As usual, Adam Rowh slayed the beer selection with a killer Scottish ale as well as these lovely articles. Enjoy…. Direct Download The papers Less is more for low back […] - Emergency medicine podcasts, reviews and curbside consults [...] How to learn from a lecture Amal Mattu stops by to talk about the best way to get the most from attending (as well as giving) a lecture. Hint, it’s not the the transfer of information. Amal says that lectures have one of two purposes: to persuade or  inspire. Direct Download   To get the most out of attending a […] - Emergency medicine podcasts, reviews and curbside consults [...] Examining mental health patients When you examine a patient who presents with a mental health complaint, let’s say they are depressed and psychotic, how do you do it? Do you listen to their lungs and heart, check for pitting edema? You might, if the history dictates. We are also responsible for a medical screening exam, but regarding the focused mental […] - Emergency medicine podcasts, reviews and curbside consults [...] Nasal suction. Miraculous simplicity It is bronchiolitis season my friends. Even I have a bit of the URI. When we’re talking bronchiolitis, the conversation is almost always about: do steroids or bronchodilators work, what to do with a touch of hypoxia. Important conversations to be sure, but the highest yield pearl I have ever received about bronchiolitis (or any […] - Emergency medicine podcasts, reviews and curbside consults [...] Articles you need to know – winter edition There’s a journal club in my living room every few months (or at least there will be – this was the first). Raconteur Adam Rowh, MD joins the show to talk the med lit we dissected by the fireside. Direct Download Stuff in this show Prandoni, Paolo, et al. “Prevalence of pulmonary embolism among […] - Emergency medicine podcasts, reviews and curbside consults [...] Mumps It’s time for a mumps outbreak! Here is a basic primer on the very basic basics. Direct Download   How do you get mumps?  Respiratory secretions, that guy sitting next to you on the airplane with the huge parotid gland and just sneeze in your eye. Not good. Incubation period How long does this […] - Emergency medicine podcasts, reviews and curbside consults [...]

    The Problem ECG interpretation is a cornerstone of Emergency Medicine (EM). It requires both rapid identification of life-threatening abnormalities and fastidious attention to detail. This pairing can intimidate some junior learners, and identifying an effective and engaging method for teaching ECGs is important to resident education. We report a teaching method that addresses this problem [...] The post IDEA Series: Teaching ECGs through a Written Competition appeared first on ALiEM. [...]

    Why do we splint? Splinting is one of the fundamental procedures of the Emergency Department (ED). How well-versed are we with it? Why do we even splint? By the end of this post, you will know the reason why we splint, when to splint, and just as importantly — when NOT to splint in the ED. [...] The post SplintER Series: Splint Principles 101 appeared first on ALiEM. [...]

    The purpose of the SplintER series is to teach the fundamentals and introduce advanced concepts of splinting to the Emergency Medicine (EM) professional. Humans have been splinting their injuries since 1300 B.C.1 Although the fundamentals have not changed, splint selection and application require some thoughtful consideration. A 2017 prospective, observational study in the Journal of [...] The post SplintER: A New Series on Orthopedic Injuries and Splinting appeared first on ALiEM. [...]

    Our work isn’t easy, but it would be impossible without the help of our colleagues. It’s time for our second post on How Our ED Colleagues Stay Healthy in EM! Liz Crowe is an Advanced Clinical Social Worker from Brisbane, Australia. She is no stranger to the FOAMed world, and her electric personality is infectious. Always [...] The post I am Liz Crowe, Advanced Clinical Social Worker: How I Stay Healthy in EM appeared first on ALiEM. [...]

    Our latest ALiEM Card introduces the “Rule of 2’s,” a simple method that uses eye anatomy to help you recall some of the major ocular diagnoses! It builds a framework for your physical exam and will help you include or eliminate some of the more common ocular conditions. The Rule of 2’s is easy to remember: [...] The post Using Eye Anatomy to Recall Key Diagnoses: The Rule of 2’s appeared first on ALiEM. [...]

    A young man is brought into an emergency department after an electric lawn edger cut through his work boot and into the dorsum of his right foot. He has a clearly contaminated 5 cm x 1 cm laceration on the lateral side, and an underlying tendon is exposed. Sensation is diminished around the wound and [...] The post Extensor Tendon Lacerations to the Foot appeared first on ALiEM. [...]

    Dr. Linda Regan is an emergency physician from Baltimore, Maryland. When she’s not on shift, she can be found taking care of her residents and colleagues, always placing others before herself. Dr. Regan’s holistic approach to her career and everyday life is something for all of us to emulate! When she’s not occupied with one [...] The post I am Dr. Linda Regan, EM Program Director: How I Stay Healthy in EM appeared first on ALiEM. [...]

    If you have spent any time working in an emergency department in the last 10 years, you have undoubtedly come across a conversation about wellness and burnout in medicine. Despite increasing awareness, the data is bleak: Emergency Medicine (EM) physicians experience burnout more than any other specialty.1 As we consider that EM was the second [...] The post 26 Best Wellness Apps for Emergency Physicians | A Wellness Think Tank Initiative appeared first on ALiEM. [...]

    Robust and comprehensive studies now support specific management guidelines for patients presenting with different intracranial hemorrhages (ICH). From the Emergency Department perspective, the primary dilemmas involve specific blood pressure goals and whether seizure prophylaxis with phenytoin is necessary. The Brain Trauma Foundation provides an excellent summary of the current guidelines.1 Summary Table on the Management [...] The post Update on the ED Management of Intracranial Hemorrhage: Not All Head Bleeds Are the Same appeared first on ALiEM. [...]

        The Problem Difficult airways, including those that are edematous, burned, soiled, or traumatic, pose one of the greatest procedural challenges for emergency physicians. Furthermore, unanticipated difficult airways represent 5-15% of intubations in the ED. Emergency medicine residents gain experience with difficult airways largely through hands-on practice while caring for critically ill patients. The [...] The post IDEA Series: Video Review as an Experiential Model for Difficult Airway Education appeared first on ALiEM. [...]

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    Lit Bits: Sept 17, 2017From the recent medical literature...1. Oxygen Therapy in the EDA. Suspected AMIHofman R, et al. N Engl J Med 2017 Aug 28 [Epub ahead of print].Background The clinical effect of routine oxygen therapy in patients with suspected acute myocardial infarction who do not have hypoxemia at baseline is uncertain. Methods In this registry-based randomized clinical trial, we used nationwide Swedish registries for patient enrollment and data collection. Patients with suspected myocardial infarction and an oxygen saturation of 90% or higher were randomly assigned to receive either supplemental oxygen (6 liters per minute for 6 to 12 hours, delivered through an open face mask) or ambient air. Results A total of 6629 patients were enrolled. The median duration of oxygen therapy was 11.6 hours, and the median oxygen saturation at the end of the treatment period was 99% among patients assigned to oxygen and 97% among patients assigned to ambient air. Hypoxemia developed in 62 patients (1.9%) in the o [...]

    Lit Bits: Aug 17, 2017From the recent medical literature...1. Acute HF in the ED: Door-to-Furosemide Time MattersMegan Brooks. Medscape. July 07, 2017 CIBA, JAPAN — For acute heart failure (HF) patients arriving in the emergency department (ED), administration of intravenous (IV) furosemide within 1 hour is independently associated with lower in-hospital mortality, according to results of the observational REALITY-AHF study[1].Yet only about a third of these patients are treated within the first hour, the study found. "That was the most surprising finding for us, because we assumed that we are doing much better," Dr Yuya Matsue (Kameda Medical Center, Ciba, Japan) told|Medscape Cardiology."We don't know exactly what causes this delay, but our results are suggesting that we are treating very obvious AHF quickly, but when the diagnosis is not clear from their symptoms, we are taking our time even though such patients could be at high risk," added Matsue.The emergency depa [...]

    From the recent medical literature...1. On Hemorrhaging in Pts on DabigatranA. Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr, et al. N Engl J Med. 2017 Jul 11 [Epub ahead of print].IntroductionPatients who are receiving oral anticoagulant therapy for the prevention or treatment of thrombosis may benefit from anticoagulant reversal if they present with life-threatening bleeding or if they will be undergoing urgent surgery or intervention. Therefore, the availability of specific reversal agents has the potential to improve the benefit–risk profile of long-term anticoagulant therapy and to increase patient and physician acceptance of such treatment. Idarucizumab is a humanized monoclonal antibody fragment that binds dabigatran with high affinity and specificity and rapidly reverses its anticoagulant activity.1 Idarucizumab has been licensed in many countries, in part on the basis of the results of an interim analysis of data on the first 90 patients enrolled in [...]

    From the recent medical literature... 1. Effect of Cephalexin plus TMP-SMX vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A RCTMoran GJ, et al. JAMA. 2017 May 23;317(20):2088-2096. Key PointsQuestion  Does cephalexin plus trimethoprim-sulfamethoxazole yield higher clinical cure rates than cephalexin alone for treatment of patients with uncomplicated cellulitis?Findings  In this randomized clinical trial of 500 patients with cellulitis, the clinical cure rate was not significantly different between those treated with cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin plus placebo (83.5% vs 85.5% in the per-protocol analysis and 76.2% vs 69.0% in the modified intention-to-treat analysis). However, the 95% confidence interval for the difference in the intention-to-treat analysis was −1.0% to +15.5%, which included the minimal clinically important difference of 10%.Meaning  Addition of trimethoprim-sulfamethoxazole to cephalexin did not result in a statistically [...]

    From the recent literature...1. Recent PE ResearchA. PE and DVT in Pts Hospitalized With Syncope: A Multicenter Cross-sectional Study in Toronto, Ontario, CanadaVerma AA, et al. JAMA Intern Med. Published online May 8, 2017. This study is a response to Prandoni et al. NEJM 2017 here: prevalence of pulmonary embolism (PE) among patients hospitalized with syncope is uncertain. The recently published Pulmonary Embolism in Syncope Italian Trial (PESIT)1 systematically evaluated patients hospitalized with a first episode of syncope and determined that 17.3% had a PE. It is not known how commonly patients hospitalized with syncope are investigated for PE or deep venous thrombosis (DVT) in routine practice.Methods | We conducted a retrospective cross-sectional study at 4 hospital sites in Toronto, Ontario, Canada, that were participating in the General Medicine Inpatient (GEMINI) cohort study. The GEMINI study has linked electronic clinical data [...]

    From the recent medical literature...0. The Science of Humor Is No Laughing Matter (in honor of April Fools’ Day)Alexandra Michel. Observer, April 2017, from the Association for Psychological Science In 1957, the BBC aired a short documentary about a mild winter leading to a bumper Swiss spaghetti crop in the town of Ticino. In a dry, distinguished tone, BBC broadcaster Richard Dimbleby narrates how even in the last few weeks of March, the spaghetti farmers worry about a late frost, which might not destroy the pasta crop but could damage the flavor and hurt prices. The narration accompanies film footage of a rural family harvesting long spaghetti noodles from trees and laying them out to dry “in the warm Alpine sun.”Naturally, the hundreds of people who called the BBC asking where they could get their own spaghetti bushes hadn’t noticed the air date of the news clip: April 1st. The prank was so successful that even some BBC staff were taken in, leading to some criticism about using a s [...]

    Lit Bits: March 18, 2017From the recent medical literature...1. Prospective and Explicit Clinical Validation of the Ottawa HF Risk Scale, with and without Use of Quantitative NT-proBNP.Stiell IG, et al. Acad Emerg Med. 2017 Mar;24(3):316-327OBJECTIVES: We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS.METHODS: This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days.RESULTS: We enrolled [...]

    From the recent medical literature...0. Kids with Blunt Head TraumaA. The PECARN TBI rules do not apply to abusive head trauma.Magana JN, et al. Acad Emerg Med. 2016 Dec 31 [Epub ahead of print]The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules were developed to identify children at very low risk for clinically-important TBIs (ciTBIs), for whom computed tomography (CT) scans can typically be obviated.1 The PECARN prediction rules have been validated in several settings and countries.2-5 The PECARN TBI rules, one developed for children younger than 2 years, and the other for those 2 years and older, rely on accurate patient history and physical examination findings gathered at the time of emergency department (ED) presentation.B. Which Children with Mild Head Trauma and Intracranial Injury Need the ICU?Greenberg JK, et al. JAMA Pediatr. 2017 Feb 13 [Epub ahead of print]Key Points Question: Can routine clinical and imaging variabl [...]

    From the recent medical literature...-1. BMJ on New Year’s ResolutionsSixty seconds on . . . New Year resolutions.Hawkes N. BMJ 2016;355:i6845 Made any New Year resolutions? Not really. I follow Oscar Wilde: “Their origin is pure vanity. Their result is absolutely nil.” Bit harsh, surely? Possibly, but the psychological literature isn’t terribly encouraging. One study showed that 22% of people who made them admitted failure after only a week, 40% at a month, 50% at three months, and 81% after two years. Most likely the real figures were even higher, because these were self reported.1 Yet people still make resolutions They do. The change of year seems to offer a chance to change lifestyle as well as date. Giving up smoking, losing weight, or drinking less are the commonest. Among students, resolving to work harder is common. And they all come to naught? Not entirely. People can change, though it’s hard. Even if only a small proportion succeed, that’s better than nothing. The psychologic [...]

    From the recent medical literature...0. Light-hearted Studies from the 2016 BMJ Christmas IssueA. Gotta catch’em all! Pokémon GO and physical activity among young adults: difference in differences studyConclusions: Pokémon GO was associated with an increase in the daily number of steps after installation of the game. The association was, however, moderate and no longer observed after six weeks.Full-text (free): Do celebrity endorsements matter? Observational study of BRCA gene testing and mastectomy rates after Angelina Jolie’s New York Times editorialConclusions: Celebrity endorsements can have a large and immediate effect on use of health services. Such announcements can be a low cost means of reaching a broad audience quickly, but they may not effectively target the subpopulations that are most at risk for the relevant underlying condition.Full-text (free): Dispelling the nice or naughty myth: retr [...]

    Since the first description of acute respiratory distress syndrome (ARDS), various consensus conferences (including American-European Consensus Co... Click to view the rest [...]

    Hyperkalemia is a potentially life threatening problem which can lead to cardiac dysrhythmias and death.  Drug interactions inducing... Click to view the rest [...]

    The blue-ringed octopus (genus Hapalochlaena) is normally found in the Great Barrier Reef and other coastal waters and tide pools around Au... Click to view the rest [...]

    Post-Arrest Tidal Volume Setting Most patients with ROSC from out-of-hospital cardiac arrest undergo endotracheal intubation and me... Click to view the rest [...]

    Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection.  What are the adve... Click to view the rest [...]

    During the past several years, several new classes of diabetic medications were introduced for clinical use, including SGLT2 inhibitors (c... Click to view the rest [...]

    IV vs. Non-IV Benzodiazepines for Cessation of Seizures A meta-analysis by Alshehri et al. included 11 studies with a total of 163... Click to view the rest [...]

    Negative-pressure pulmonary edema (NPPE) is a well-documented entity that occurs after a patient makes strong inspiratory effort against a ... Click to view the rest [...]

      Viscosupplementation Hyaluronic acid (HA) is a high-molecular weight polysaccharide A major component of synovial fluid and of c... Click to view the rest [...]

    Radiographs studies can be valuable in poisoning diagnosis, management, and prognosis.  Radiographic imaging should be utilized fo... Click to view the rest [...]

    Acute gastrointestinal disorders are some of the most frequent problems evaluated by ED physicians.  Complaints of diarrhea account for almost 5% of visits to the emergency departments (Bitterman, 1988).  Although the disease entity is extremely prevalent and current evidence on the … Continue reading → [...]

    1. When do you send stool cultures, stool ovum and parasites, and/or fecal WBC? How do you use the results in diagnosis and management? 2. When do you get bloodwork? When do you pursue imaging? 3. Which patients do you treat with antibiotics? 4. What other … Continue reading → [...]

    1. When do you use NIPPV in status asthmaticus? The use of NIPPV (non-invasive positive pressure ventilation) for respiratory failure has been proven to be beneficial and widely accepted in practice for multiple indications including COPD exacerbations and pulmonary edema … Continue reading → [...]

    1. When do you use non-invasive positive pressure ventilation (NPPV) in status asthmaticus? 2. Do you start inhaled corticosteroids on asthma patients who are going to be discharged from the ED? 3. When, if ever, do you use ketamine for induction, or for … Continue reading → [...]

    In which patients with syncope do you get a NCHCT? Syncope is defined as a transient loss of consciousness and postural tone. It has a rapid onset, short duration, spontaneous recovery and is due to transient global cerebral hypoperfusion. It … Continue reading → [...]

    1. In which patients presenting with syncope do you get a Non-Contrast Head CT (NCHCT)? 2. In which patients presenting with syncope do you get a troponin? 3. Do you get orthostatic vital sign measurements in patients presenting with syncope? How do you … Continue reading → [...]

    1. What imaging do you use for patients with possible acute, traumatic spinal cord injury? Patients who can be cleared using the Nexus or Canadian C-spine criteria should be cleared clinically. However, those with moderate to high risk of a … Continue reading → [...]

    1. What imaging do you use for patients with possible acute, traumatic spinal cord injury? 2. How do you treat neurogenic shock? 3. What is your management and disposition for elderly patients with vertebral compression fractures? 4. How do you … Continue reading → [...]

    1. Which patients with neutropenic fever do you consider for outpatient management? Neutropenic fever is a common presentation to the Emergency Department, especially in tertiary hospitals where many oncology patients are undergoing chemotherapy. According to the Infectious Disease Society of … Continue reading → [...]

      1. Which patients with neutropenic fever do you consider for outpatient management? 2. Which patients with community-acquired pneumonia do you admit? 3. Which patients with influenza do you treat with oseltamivir? 4. Which adult patients getting worked up for a … Continue reading → [...]