Author Archive for: srrezaie

Usefulness of the Pelvic Examination in 1st Trimester Vaginal Bleeding

16 Oct
October 16, 2017

Background: First trimester vaginal bleeding is a common complaint seen in the emergency department.  Patients are obviously stressed about the possibility of miscarriage while providers are stressed about missing diagnoses such as ectopic pregnancies.  There have been multiple studies questioning the interrater reliability of the pelvic examination. A more important question however, is does the pelvic examination provide any benefit to these patients by enhancing management and decreasing morbidity? Read more →

Do Patients with Opioid Dependence Benefit from Buprenorphine/Naloxone Treatment Initiation in the Emergency Department?

09 Oct
October 9, 2017

Background: North America’s current opioid crisis, much of it iatrogenic (2), has led to significant increases in ED visits associated with opioids (3). These patients often present after poisoning, in withdrawal, or with other health issues associated with their disease.

It is well accepted that Opioid Replacement Therapy (ORT), namely, methadone and buprenorphine/naloxone, are successful harm reduction agents shown to improve health and social outcomes (4). Several individual providers, and even large academic institutions, have started initiating ORT, specifically buprenorphine/naloxone, in the ED when dependent patients present in withdrawal.

D’Onofrio et al., in 2015, published outcomes after 30-days from a clinical trial of patients who met criteria for opioid dependence in the ED that were randomized to one of three interventions: referral, brief intervention or ED-initiated buprenorphine followed by 10 weeks of continued buprenorphine treatment in a primary care setting (5). They found that patients receiving ED initiated buprenorphine with continuation in primary care were more likely to be engaged in formal addiction treatment at 30 days (p < 0.001). More recently, they have published follow-up outcomes on a subset from the original study at 2, 6 and 12 months. Read more →

Topical Pain Control for Corneal Abrasions

05 Oct
October 5, 2017

Corneal abrasions account for 10% of all ocular complaints, and are the most common cause of ocular trauma (Alotaibi 2011, Bhatia 2013).  The diagnosis of corneal abrasions typically involves fluorescein staining of the eye and visualization of the abrasion via slit lamp exam. This review focuses specifically on pain control for corneal abrasions.

Although corneal abrasions typically heal within 24-72 hours without complications, the pain in the acute phase is usually significant (Wilson 2004).  Treatments described include patching, topical anesthetics, topical NSAIDS, cycloplegics or oral analgesics.  Utilization of topical anesthetics has been described in a previous post.  Oral analgesics are usually prescribed as a rescue modality when topical treatment is ineffective at managing pain.  Read more →

Is Contrast Induced Nephropathy (CIN) Really Not a Thing?

25 Sep
September 25, 2017

Background: One of the most common imaging modalities used in the emergency department (ED) today is computed tomography (CT) scans using intravenous radiocontrast agents. Use of IV contrast can help increase visualization of pathology as compared to non-contrast CTs. However, many patients do not get IV contrast due to fear of contrast induced nephropathy.  Furthermore, waiting for renal function values delays the care of patients and prolongs time spent in the ED with a potential to increase adverse effects on patient centered outcomes due to delays. Read more →

Turn it (All the Way) Up: Flush Rate O2 for Pre-Oxygenation

14 Sep
September 14, 2017

Background: There has been a lot of buzz recently about the importance of pre-oxygenation in emergency airway management.  The recent publication of the ENDAO trial [2], a randomized clinical trial of ApOx vs no ApOx also emphasized this point.  In the review article accompanying this trial by John Sackles [3] he brought up the point that most patients in this study were intubated in less than 1 – 2 minutes.  In this scenario, preoxygenation alone would likely provide an adequate oxygen reservoir to prevent hypoxemia and that apneic oxygenation would only be helpful in the patients who exhausted their oxygen reserves (i.e. prolonged intubations). Although, apneic oxygenation has recently come into favor in emergency intubation, the issue that should maybe warrant greater consideration is proper preoxygenation. The optimal method of pre-oxygenation however, is often debated: bag-valve mask (BVM), nonrebreather (NRB), or simple face mask.  Read more →

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