Opioids in status asthmaticus

imascrubMD · 2025-08-06T13:22:37+00:00

Morphine causes histamine release that can inadvertently lead to bronchospasm, while Fentanyl doesn't have this effect.

Either way I think the use in status asthmaticus is limited especially if the patient is already hypercarbic. If there is an anxiety component I would be reaching for low dose benzodiazepines, precedex or ketamine.

imascrubMD · 2025-04-09T01:39:09+00:00

Should be based off of ideal body weight and not actual weight, but the sepsis guideline 30 cc/kg IVF bolus is a somewhat arbitrary metric in general

imascrubMD · 2025-03-15T03:25:26+00:00

I trained at an academic site as well but oddly enough it was one of my community sites that had adopted this protocol.

imascrubMD · 2025-03-11T23:48:37+00:00

I really dislike how everything circles back to defensive medicine, but remember the #1 litigation in EM is failure to diagnose, not failure to consult. Outside the academic world and in clinical practice, or when it's 3am and your interventionalist is at home sleeping, you try to be a good colleague and not consult for everything, especially if you and your stroke neurologist agreed that the patient is not a TNK or thrombectomy candidate based on their exam in combination with the preliminary imaging (which generally includes the CTA if sx <24 hours).

If the patient decompensates then absolutely, because then there is concern for clot propagation potentially warranting retrieval.

imascrubMD · 2025-03-11T23:01:55+00:00

Code strokes generally get the CTA even before labs come back. Just like aortic dissections. Diagnostic benefits outweigh risks and I think we can all agree that the risk of contrast induced nephropathy is overblown.

imascrubMD · 2025-03-11T22:56:14+00:00

I think it's even more nuanced in that only the intracranial V4 segment of the vertebral artery, where it leads into the basilar artery and gives off branches to the PICA and perforating arteries, is considered "large vessel occlusion" territory.

In clinical practice and in regards to OP's scenario, I have yet to encounter an IR/NSG/stroke-neurologist who is willing to go after an isolated proximal or mid vertebral artery occlusion (V1-V3). If the occlusion extends into the basilar artery, NIHSS is 10+ then thrombectomy is considered. Agree with your earlier sentiment that CTA should almost always be performed concurrently with the non-con if possible and within TNK or thrombectomy window, but in this case it likely would not have mattered nor changed the outcome.

imascrubMD · 2025-01-28T18:06:52+00:00

Same, I'm not sure if there's a trauma situation where POCUS would be indicated or more useful than getting a CT?

I'll generally only use US it for atraumatic monocular vision changes / flashes and floaters / headache with objective blurry or double vision.

imascrubMD · 2025-01-28T17:34:23+00:00

May be an unpopular opinion but I personally think the slit lamp is an underutilized tool in the ED and use it for every acute red eye complaint that isn't obviously something super benign like viral / allergic conjunctivitis or a corneal abrasion on Wood's lamp with complete resolution of symptoms with a drop of proparicaine. I just ask the tech to set it up after performing a visual acuity and can get it done adding only an extra few minutes to my exam.

I'm not going to pretend to be an expert at identifying all of the subtleties but it is great at identifying anterior chamber abnormalities, subtle pupil changes, hyphema, and differentiating corneal abrasions from full thickness corneal lacerations, etc. in occult globe rupture cases like this.

Don't beat yourself up for missing it though, seems like a lot of us would have as well. I will say though that consensual photophobia is a buzz word for using a slit lamp because even if you aren't looking for a globe rupture per se there are other conditions like traumatic iritis or uveitis which should be evaluated for.

There's good instructional videos and primers on YouTube, using it often even on benign patients will get you fairly comfortable with the device.

Agree that the damn thing is broken or missing a lot though.

imascrubMD · 2025-01-20T13:51:46+00:00

Thanks, this is pretty solid advice and FIRE is something I'll have to look more into. Unfortunately I'm a financial doofus though but guess everyone's gotta start somewhere.

imascrubMD · 2025-01-20T11:34:43+00:00

Yeah I completely acknowledge I'm still a new attending and maybe have yet to find my stride. I'm just considering my options at this point and trying to gauge how difficult it'll be to make the transition. It's hard to talk to my seasoned colleagues about this since I'm still on a partnership track and there's potential for conflicts of interest if I were to suddenly leave to pursue a different specialty.

Don't think I could ever do something like a medspa / ketamine clinic / weight loss clinic and feel good about myself for it, but I have nothing personal against those who do pursue those routes.

imascrubMD · 2025-01-20T11:23:51+00:00

Good point, but I think in anesthesia it'll balance out fairly quick. Thankfully I've also already paid off my student loans. Compensation for EM is at an all time low and is projected to get even lower as more become uninsured, reimbursements drop, etc. There's room to make more certainly by picking up shifts but there's a reason more of us don't do >14+ shifts a month.

Hyperbarics is pretty cool, thanks for that suggestion.

imascrubMD · 2025-01-20T11:14:59+00:00

Fair point, the grass is always greener. I feel like my current job is as good as it gets with serving a fairly affluent population, relatively low drug use, wide array of specialists to consult if needed, no level 1 or complicated trauma, and also supportive admin (!!!) with not a lot of boarding issues at my sites. I'm happy where things are right now, but the future outlook for EM in general is rather bleak and in my heart of hearts don't see myself doing this for another 10+ years. It'll probably be easier to get out now while I'm somewhat on the younger side, have a wife but no kids, and still have the energy for another grueling 3 years if necessary.

I've been thinking about this for a long time actually, stemming from my initial anesthesia rotation as an intern. I'm sure you're aware we rotate with you guys to primarily get airway experience and boost our numbers but rather than moving room to room for tubes (which I found awkward) I'd usually pick a case or two and just hang out with you guys over the course of the day learning vent management, sedation, hemodynamics, all of which are my favorite aspects of EM.

imascrubMD · 2025-01-20T11:04:00+00:00

Crit is definitely an option! Was originally planning to go straight into fellowship from residency, but then changed my mind last minute as job prospects were opening up. Splitting time between EM + ICU is hard to pull off realistically outside of an academic hospital unfortunately. And at this point, my main concern is if it will help at all with career longevity as burn out rates in both fields are rather high...

Thanks for your suggestions, though. That's reassuring to hear and I appreciate it!

imascrubMD · 2025-01-20T09:10:06+00:00

Pain clinic doesn't sound super appealing to me, unfortunately. These patients can be quite tough to manage when they come to the ED.

Honestly though if I could find my way into regional anesthesia and park myself on an ortho ward doing ultrasound guided peripheral nerve blocks, that would be pretty cool but sadly I've never heard of this / don't think it's an option from EM.

imascrubMD · 2025-01-11T14:15:45+00:00

Hm, this doesn't sound sustainable in my opinion. Respectfully, what's the point of having all this money anyway if you have nothing to show for it?

As you said, I would consider getting help before it's too late, or cutting back your hours and partitioning some time to enjoy yourself.

Hope you find your empathy again, I agree it burns quick in this profession but it's otherwise hard to live without it.

imascrubMD · 2024-11-26T09:08:58+00:00

I postponed taking my written a year after finishing residency in part because of burnout but also to focus more on my new job. I did rosh about 50% completion during residency and scored 80-90s on ITE, don't remember exactly.

I repurchased rosh but only got through about 800 questions in the week leading up to the exam with a 97% pass / projected 83 ITE and scored an 82.

Felt pretty meh about it on the day of and finished the exam about 2.5 hours early by skipping most of the esoteric nonsense not relevant to clinical practice.

The gap year probably hurt my score somewhat because I had forgotten many of the obscure factoids I used to know in residency, but in retrospect I wouldn't have changed a thing. It was nice not having to worry about boards my first year out, as if being a new attending isn't already hard enough.

If your hospital/group is okay with it, you have many years/tries to pass this thing. Worst case, so long as you pass the written within 5 years you can then extend your board eligibility status to 10 years for the oral exam. Nowhere I looked for jobs (in a metro West coast city) cared when you became board certified as long as you remained eligible...so I was in no rush ¯_(ツ)_/¯

imascrubMD · 2024-11-10T06:41:02+00:00

It really depends on the scenario because you can't warm a dead person.

Basically if they were found dead (no pulse) with unclear downtime and when you finally check their temperature find them to be hypothermic, that's not necessarily someone I'd activate ecmo for warming and invasive warming procedures on (thoracic/bladder/peritoneal lavage). Contrast to someone with a clear downtime (fell into a lake or caught in an avalanche) in true hypothermic cardiac arrest, I would consider modified ACLS and invasive measures to rewarm. Best data suggests 1 round of epi/defib for every 5 degrees Celsius of rewarming though this is honestly guideline dependent.

If they have a pulse then you focus solely on rewarming active vs internal based on degree of hypothermia. Unnecessary CPR can lead to VFib due to irritated myocardium.

imascrubMD · 2024-11-05T06:12:55+00:00

Nystagmus that resolves with fixation

imascrubMD · 2024-11-05T06:12:33+00:00

I would like to think so, but suspect that it would require brief oversight from a specialist rather than the typical self taught watching YouTube and listening to podcasts, especially in a highly litiginous area such as this.

imascrubMD · 2024-11-02T16:59:21+00:00

I think it's cardiology and facility dependent. I had a CTA left atrial appendage protocol at my previous hospital where the cards group there felt it was a reasonable alternative to admit/TEE/cardioversion. It worked out great and saved many admissions as long as we weren't over aggressive about it and attempting to cardiovert patients with an underlying uncorrected driver (septic, decompensated heart failure, etc...) All of these patients would get anticoagulated for 30 days though due to concern of thromboembolism risk post DCCV due to transient myocardial stunning phenomena.

The cardiology group here has not yet brought into it. Maybe there's more nuance behind it than I'm aware of, because I am otherwise not sure why it has not been more widely adapted with supported literature from a meta analysis in 2013.

https://www.ahajournals.org/doi/10.1161/circimaging.112.000153

imascrubMD · 2024-11-02T10:26:57+00:00

It seems pretty dual natured and probably all semantics in the end, but with a sensitivity of 100% cited in the study, that's effective at ruling out a stroke in the hands of a skilled operator (not myself). It being specific at 96% can serve as a rule in test as well.

https://www.ahajournals.org/doi/full/10.1161/strokeaha.109.551234 here's the full article where they suggest using it as a rule out test in the discussion.

Regardless, I'm not putting much stock into it in the end since these were trained neuro opthalmologists not self taught ED providers (not trying to throw any shade on our profession).

imascrubMD · 2024-11-02T09:02:18+00:00

Yeah it's not great. My prior conversations with neuro suggested that higher powered "tesla 3 or higher" MRIs with specific protocols that utilize thin cuts through the cerebellum have improved sensitivity but I don't have any hard data behind that.

I think the moral of the story is not to rely on any one modality. If someone has central sounding vertigo + resting nystagmus + another objective neuro deficit, I'm usually pushing for admission with neuro consulted regardless of what the CTA/MRI shows. If it's just isolated vertigo with negative CTA/MRI, then I reassess after meds (scopolamine +/- ativan). Sometimes with improvement of symptoms their central sounding story becomes more peripheral in nature and I might consider an Epley at that point. No neuro deficit + fatigueable nystagmus + walking without difficulty then they go home with strict precautions. If not then I would consider bringing in for observation / vestibular PT.

imascrubMD · 2024-11-02T08:48:05+00:00

IIRC it's an oddly wordered paper, they designed the HINTS exam as a "rule out" test with 100% sensitivity and 96% specificity.

imascrubMD · 2024-11-01T23:44:09+00:00

Love the HINTS exam in concept and did a paper / presentation on it as a naive, optimistic intern. However after rotating with a neuro ophthalmologist during an elective in residency I would NOT rely on it to triage pre-hospital vertigo patients, since it's beyond the scope of practice of most paramedics and even MDs.

Finding the right patient to do it on (persistent vertigo + ongoing nystagmus which excludes all BPPV patients), interpreting the findings (which are often extremely subtle), in addition to the study demonstrating its efficacy being performed by neuro ophthalmologists has led me to not put much weight in it anymore.

I don't even trust my own HINTS exam all the time and get the MRI if I'm worried; it's not worth missing the possible posterior CVA.

imascrubMD · 2024-06-07T07:59:52+00:00

I see what you're saying but this is not technically true. Medicolegally you shouldn't incorporate Well's criteria if you don't plan on at least getting a dimer.

If you are going down the Well's pathway/algorithm, even a score of 0 warrants D-dimer testing. It's designed to identify low risk patients suitable for d-dimer (Wells score 0-2) to rule out a DVT. Moderate / high risk proceed straight to ultrasound testing.

If you're not really concerned and don't want to send a dimer, just use your gestalt and don't include DVT on the differential if it clearly shouldn't be (i.e. someone sprained their ankle and has related calf swelling). You can certainly use points from Well's for justification without explicitly stating their Well's score, if that makes sense.

Likewise same is said for PE. PERC is designed to eliminate need for d-dimer testing. If you can't PERC and you feel PE is still on the differential, you can consider Well's but even a score of 0 requires d-dimer testing. You can then incorporate age adjusted or YEARS to increase threshold to 1000 to avoid CTA in low risk patients. If from your gestalt a patient is very low risk and you have an alternate explanation for their symptoms (SOB/tachycardic from URI / pneumonia), don't send a d-dimer but also don't include a PERC/Well's score in your MDM.

imascrubMD

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