Modified Valsava for SVT

Background: SVTs are commonly seen in the ED. Chemical cardioversion often takes several minutes to initiate because we have to get IV access and medication ready.  During this time, we can attempt some valsava maneuvers to cardiovert stable patients. Current valsava maneuvers have shown low efficacy 5-20%. The REVERT trial compared the standard Valsava toRead more


What’s the difference between BiPAP vs. CPAP? CPAP stands for continuous positive airway pressure. In other words, there is a continuous pressure regardless whether the patient is breathing in or out. CPAP only has one pressure setting. BiPAP has two pressure settings: inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). While theRead more


Background: Acute aortic syndromes (AAS) include aortic dissection, intramural aortic hematoma, penetrating aortic ulcer and aortic rupture. AAS are rare but life threatening cardiovascular emergencies with non-specific clinical presentations, which results in overtesting and misdiagnosis. The ADvISED Trial introduces a new clinical strategy that combines a Pre-test Probability Assessment with a D-dimer to help physiciansRead more

4 reduction techniques of anterior mandible dislocation

4 Reduction Techniques of Anterior Mandible Dislocation Classic intra-oral reduction  Place thumbs over the patient’s inferior molars Apply downward force and then guide the mandible posteriorly Wrist Pivot Method Place thumbs at the chin Place other fingers on the inferior molars Pivot your wrists Syringe Place a syringe between the molars of one side AskRead more


Clinical Scenario: 28 yo F with unknown medical history presents with multiple seizures. Routine BMP shows hyponatremia to 110. What is your next step for symptomatic hyponatremia? Causes of hyponatremia: Hypervolemic Hyponatremia: congestive heart failure, cirrhosis, chronic renal failure Euvolemic Hyponatremia: SIADH, hypothyroidism, adrenal insufficiency Hypovolemic Hyponatreamia: fluid loss via the gastrointestinal tract, diuretics, renalRead more

Codeine is bad for children

Despite warnings by the FDA in 2013 to stop prescribing codeine to children due to the risk of respiratory depression and death, a study to be released this week in Pediatrics indicates that 5% of children post-tonsillectomy/adenoidectomy are still being prescribed this medication.   Why is codeine so dangerous?   Codeine is metabolized to morphineRead more

52 in 52: PECARN tool to identify pediatric patients with low risk head injuries

Article Citation                                                                                                                             Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.    What we already know about the topic According to the CDC,Read more

Presentation of acute aortic dissections

A 91 yo female presents with sudden onset right arm pain with decreased pulses. Since arrival to the ED, her mental status has also progressively decreased. Her blood pressure is 170/60, HR 60, T97.8, RR20, sats 100% RA. You suspect she has had an aortic dissection and indeed a CTA of her chest / abdomenRead more

Combination of acetaminophen and ibuprofen for acute extremity pain

Article Citation                                                                                                                             Chang AK et. al. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial.JAMA. 2017 Nov 7;318(17):1661-1667. doi: 10.1001/jama.2017.16190.   What we already know about the topic According to the latest CDC data from 2015, opioids were involved inRead more

IUDs and the risk for ectopic pregnancy

17 yo female with progestin secreting IUD, LMP 9/22/17, no prior medical problems presents to the ED with bilateral lower abdominal pain for the last day. She also notes that she has had some intermittent vaginal bleeding for the last 3 weeks. Her HR is 98, BP 130/99, RR16, sat 100% on RA. On examRead more