Renal Colic & the CT scan: flip your patient prone!

A CT abd/pelvis without contrast is one of our go-to studies when evaluating for nephrolithiasis in a patient with acute flank pain. And it’s a really good one too–a recent meta-analysis of CT for suspected renal stone showed a sensitivity of 97% and a specificity of 95%. Pretty, pretty excellent. But have you ever wonderRead more

Kayexalate in Hyperkalemia – to give or not to give?

When a patient presents with hyperkalemia, in addition to the initial steps of obtaining an EKG and treating with calcium, insulin, glucose, albuterol, and furosemide if indicated, consultants will often ask us to also administer sodium polystyrene sulfonate, more commonly known as kayexalate, pending hemodialysis. Is this management strategy supported by evidence? Reviewing the (ratherRead more

ER venous panel or BMP?

You have a patient who is in acute renal failure. You have sent an ER-venous panel that shows a Cr of 4.6, a BUN of 95, and a K of 6.5. You discuss these findings with your nephrology colleagues who request you get the “more accurate” basic metabolic panel. But is it?   Answer: ItRead more

How much toradol?

Current FDA dosing for Toradol is 30mg IV and 60mg IM in patients < 65 years old.  But is that necessary? Let’s look at this randomized controlled trial: Motov S et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg MedRead more


  Dr Smith ECG blog: note STD in inferior leads and STE in V1 and V2 “Brugada-like pattern” Dr. Smith ECG Blog: note peaked T waves Ours Truly: widened QRS, disappearance of PR intervals, interventricular conduction abnormalites with PVCs…badness                     What do all these EKGs haveRead more

Pregnancy Pain

A 29 y/o F 20 weeks pregnant presents with fever, dysuria, and left flank pain. She has some CVA tenderness on the right. WBC is elevated to 15. UA shows both blood and leukocytes in the urine. You are concerned about pyelonephritis vs. and infected stone. What are the risks of imaging this patient?Read more

Confused and Hypertensive

52 y/o female with a PMH of HTN and HLD presents with mental status change over the past 12 hours. She is non-compliant with medications and her initial BP is 252/130. Physical exam shows pt is A&Ox1, with an otherwise normal neuro exam. Labs show some AKI on CKD, CT-Head is normal. You plan toRead more

Ddavp for Hemorrhage in Esrd Patients

CASE: 45F h/o ESRD on dialysis presents ped struck. Pt is obtunded, intubated for airway protection. CT head shows subdural hematoma with midline shift. Neurosurgery is activated. No antiplatelets or anticoagulants. Is this person coagulopathic simply by having ESRD? If so, should we address it with any particular medication?Read more

Should You Stop Metformin After Iv Contrast?

Metformin has been known to be associated with increased incidence of lactic acidosis. Metformin is renally excreted. Increased Metformin concentration leads to increased risk of lactic acidosis. IV contrast causes nephropathy leading to increased blood levels of Metformin. Metformin + IV contrast = lactic acidosis = bad   This was the reasoning to having patientsRead more

Clinical Pearl: July 6

A 66 year old female patient presents to the ED with a transient episode of dizziness and SOB earlier today. PMH notable for stage III CKD, DM, HTN. She takes valsartan, metformin, and is currently on TMP-SMX (Bactrim) for a UTI. Her EKG shows NSR and laboratory studies reveal a confirmed K+ of 8.0 andRead more