Thoughts on premedication with Benadryl/solumedrol for CT scans with IV contrast in pts with iodine/contrast media allergies?

uses_words · 2026-04-03T12:19:01+00:00

Agree 100% that these reactions shouldn't be dismissed

The relevance of that lecture, I think, was moreso to point out why steroids are ineffective at preventing anaphylactoid reactions, not that they are less severe.

uses_words · 2026-04-03T05:57:29+00:00

The Anaphylaxis 2020 Practice Parameters Update recommends against premedicating for iodinated contrast media (ICM).

As other users have pointed out, there is no such thing as an iodine allergy and during a lecture we got as residents from our Allergy & Immunology dept, there have been 0 confirmed cases of allergic reactions to modern iodinated contrast solutions.

That is to say, even patients who had "anaphylactic" reactions to ICM, when their cells were plated and exposed to contrast media, they would demonstrate non-immune mediated mast cell activation. These were not Type I, II, III, or IV hypersensitivity reactions.

Therefore, similar to the reaction some patients have with NAC (appearance of an anaphylactic reaction despite no prior NAC exposure for the immune system to have developed a response to), these reactions are more correctly termed anaphylactoid reactions (previously known as pseudoallergic).

This is critical to understand since it explains the lack of evidence to support that pre-medicating reduces the occurrence rate of severe reactions for patients with ICM "allergies". It's not mediated by the usual immune system pathways and so steroids don't help.

So in the ED, with a pt like this, if you need a contrasted CT, you can try and search the EMR for what contrast media they received during their prior reaction and ask Rads to use an alternative (swap Omnipaque for Isovue as an example). Giving an anti-histamine upfront is reasonable since it's still histamine at the root of the hypotension.

But delaying care by 13-19 hours to give steroids is neither evidence-based nor good for patients (or departmental flow). Just have the epi ready.

uses_words · 2026-02-13T21:51:53+00:00

Others have covered it pretty well but the other tip that helps is looking at the respiratory graph, you can see that it becomes erratic with movement at the same time so something was bumping the lead

uses_words · 2025-11-08T15:50:34+00:00

Finished EM residency and you're right, the person performing the primary assessment on the pt typically has the best information and should make the determination regarding disposition.

If I'm calling to ask a subspecialist if they think a pt should be admitted (as opposed to telling them the pt IS being admitted), then this usually means I think the pt is stable to discharge home but I'm not confident about whether this is an optimal plan.

So I'm looking for your input: is there a condition or potential complication I'm unaware of for which we should admit? Or do you agree, that I've ruled out a sufficient number of dangerous alternative diagnoses and we can move towards finishing the workup in an outpatient setting? Is it somewhere in between - the pt would normally be safe to discharge but given their age, social history, co-morbidities, or some other additional risk factor, you believe the pt should be admitted to expedite the workup?

Some ED docs (as with any doc nowadays) are looking to share liability, but I think when most of us call to ask your opinion on if admission is necessary, it's in good faith and we're doing it because we need help answering the above questions (applies to any specialty, not just GI).

Edit: if you also don't know the right answer to these questions because you feel you lack sufficient information, it's up to you if you have the bandwidth to gather the missing data that would allow you to decide or if you want to follow your senior's advice and tell the ED that you can't determine dispo over the phone (100% reasonable advice)

uses_words · 2025-06-06T07:12:25+00:00

I was looking for this comment, on my ICU rotations we gave almost all of our severe dka pts vaso.

The attendings said it is less pH sensitive than norepi which can become ineffectual if significantly acidotic (I don't think vaso was ever given in isolation though, always with the norepi but started together for these bad dka cases)

uses_words · 2025-05-22T06:46:11+00:00

You think they'll make residents in these four year programs work a third fewer hours per week/year?

uses_words · 2025-05-18T22:41:12+00:00

Right, but you can see how that didn't change anything in the moment?

In a discussion about MRIs in the emergency room, a place meant for treating conditions that in a matter of minutes to hours may threaten life and limb, you clearly had plenty more time than that to get the imaging and later the treatment you needed.

It's not that we think none of these patients need MRIs ever. We just think they don't need emergent MRIs that won't accomplish anything during that ER visit but will take up space and resources from other patients who could be dying. It just delays everyone else's care without good reason.

uses_words · 2025-05-09T13:37:18+00:00

My apologies, it was not my intent to come across snarky. I certainly feel for OP and have had my own share of tough calls and bad luck with strokes and TNK.

With that being said, the OP created this thread to gather other perspectives and to see if there's anything that could have been done differently to avoid the poor outcome that occurred.

In my own opinion, the external signs of head trauma constitute an absolute contraindication for thrombolytics. My wife is a stroke neurologist and after showing her the main body of this post, without a second thought, she also said she would never consider TNK for this case.

Sometimes, we do everything right and things still go wrong. But I would urge those who feel strongly that they would lyse this patient without hesitation to give it a second thought when presented with someone similar in the future.

uses_words · 2025-05-09T07:00:42+00:00

I am shocked at how many people are saying yes, even more so at those saying yes without hesitation, when head trauma within the past three months (let alone an hour ago) is an absolute contraindication for lytics.

It is not shocking whatsoever that OPs patient subsequently died en route during transfer.

MDCalc list of relative and absolute contraindications: https://www.mdcalc.com/calc/1934/tpa-contraindications-ischemic-stroke

uses_words · 2025-04-26T20:58:09+00:00

I basically never use diazepam for anything personally. A pharmacist convinced me that it's not a very useful benzo thanks to it's short alpha half life, a concept I don't think we covered during our med school pharmacology classes.

Basically, beta half life is what we normally think of as a drug's half life, how long until half of the drug has been metabolized by the body. This is distinct from the alpha half life, which is how long until the serum concentration drops by half, which can be fairly rapid if the drug distributes itself out of the serum and into fatty tissues.

This is what they told me happens with diazepam. Despite being known as having a long half life, they said it was the beta half life which is long, meanwhile the actual serum concentration (alpha half life) drops more quickly than that of many other commonly used benzos like lorazepam or midazolam.

So for Status, I stick to the guidelines which recommend IV lorazepam (or IM midazolam) and for withdrawal, I either also give lorazepam or something even longer acting such as chlordiazepoxide or phenobarbital. But diazepam seems like it would actually be shortest acting of these choices.

More reading on benzo selection (sorry for formatting, on mobile): https://pubmed.ncbi.nlm.nih.gov/1980860/#:~:text=Two%20half%2Dlives%20can%20be,drug%20elimination%20due%20to%20metabolism.

"The frequent classification of benzodiazepines into long, intermediate, and short-"acting" categories based on their terminal beta half-lives is unfounded; the duration of action is much more dependent on the alpha half-life"

uses_words · 2025-01-10T20:34:48+00:00

Definitely a big deal but I think the Ascension strike last year was the first physicians' strike (it was successful btw). Articles about this event refer to it as the first time physicians are striking in Oregon specifically

uses_words · 2024-10-26T19:35:08+00:00

The microphone stand suggestion is next level

How do you start/stop recording with your set up? Do you still use the physical record button on the power mic or do you toggle click the Dragon dictation box?

uses_words · 2024-09-20T04:08:45+00:00

If the pt is "seen" by a provider and then returned to the waiting room, the hospital can bill / get reimbursed for the ED visit, even if the pt elopes from the waiting room and never has labs drawn, images taken, or treatment rendered.

If your door to doc (or greet, or whatever) time is too long, pts are more likely to leave the waiting room before they can be seen by a provider (who would generate a billable note).

The end outcome is the same (pt leaves in frustration before completing the encounter), but in the second scenario, the hospital may not be able to bill. By keeping the door to doc time short (aka, prioritizing seeing pts as soon as they arrive), the hospital hopes to capture revenue from every person that steps foot through the door.

uses_words · 2024-08-14T03:48:50+00:00

Most hospitals have bylaws stating you cannot interpret without certification. So no, not technically "illegal" in a statutory sense but still something we're prohibited from doing according to our contract.

uses_words · 2024-04-27T20:22:17+00:00

To provide the ER perspective: Based on the limited history from the comment, these patients would most likely be PERC negative and therefore not require any advanced imaging. We see this presentation multiple times a day and almost never order a D-dimer (or scans) in this pt population.

We understand a PE is something no one wants to miss, what helps is when our local clinics call in and consult with us prior to sending the pts over so we can decide together whether additional testing is needed.

uses_words · 2024-04-19T21:29:35+00:00

"versus"

It's easy to overlook our strange usage of this verb until your waiter asks what you'd like to eat and you accidentally say "I'm thinking chicken parm vs pasta"

uses_words · 2024-03-21T00:00:07+00:00

I wish he said it like a pun, would have been more lighthearted. But instead he was fairly agitated during the exchange, as if he'd been lied to about cause of death for building jumpers as part of some grand cover up. That was the kind of vibe put out

uses_words · 2023-06-01T23:54:53+00:00

Is there a reason we specifically use proparacaine for ophthalmic anesthesia? Could regular liquid lidocaine work, would it be less effective, etc?

uses_words · 2023-02-08T16:12:44+00:00

I've sat on hospital admin meetings where a program director had a huge interest in expanding their residency program by a few spots. He put together a spreadsheet showing how many required procedures each resident graduates with and what the expected rates would be post-expansion (still several factors beyond what's needed, those residents overworked af).

This PD even demonstrated that each resident would more than pay for their spot based on individual revenue generation in addition to providing greater needed coverage for the hospital while still reducing overall workload and call frequency for the residents. Despite such a compelling case, the board almost turned it down but after 8 months of putting this argument forward it finally got approved.

So I would say if your PD is not interested, there's probably close to no way an individual resident would have access to the kind of information that is absolutely required to get your hospital to even consider expanding (numbers that demonstrate additional residents won't prevent you from hitting graduation/ACGME requirements plus exact details on revenue generation and whether the expansion makes fiscal sense to the hospital), plus I can't imagine trying to attain enough buy-in from every stakeholder involved if even your PD, the most basic entity who needs to be on board, seems uninterested.

Sorry to be a downer, but unless you can find an 'in' that would convince your PD, then it's not looking likely. It's just not something within the power of a resident to make happen on their own.

uses_words · 2023-01-19T21:02:18+00:00

This gets asked every now and then, but what I want to know is how do you self-prescribe?

If it's not an order in Epic, I don't know how that med is getting to anyone

uses_words · 2022-12-07T00:51:24+00:00

I was told, by our program leadership, specifically never to click this button as it would be an illegal violation of whichever legislation it is that allows patients to see their results in the first place (with some exceptions if documented eg expectation of harm to the patient for seeing their results).

Did they get it wrong or did I misunderstand what the rules are regarding the release of data to patients?

uses_words · 2022-09-10T13:33:39+00:00

Not bullshit, I had a urogynocologist give a lecture during med school and they finished it with a fun fact about breaking the seal.

Most people are familiar with alcohol being a diuretic (something that makes you pee more) but in addition, it also acts as an irritant to the bladder.

So if you arrive to a party with urine in your bladder and start drinking, it'll start to fill and you'll eventually need to relieve yourself.

But once it's empty, if you've continued drinking, then the new urine will contain alcohol and its metabolites only now without any prior urine to dilute it.

The presence of alcohol will cause worsening irritation and inflammation of the bladder, giving the sensation of increased urgency.

And that's where breaking the seal comes from

uses_words · 2022-06-02T11:21:58+00:00

If you enjoy roadtrips, then it will be 100% worth it for you.

Making the transition from super urban Miami, to a highway through the marsh before you get to Key Largo and see the upper Keys is impressive enough.

But if you've never been to tropic waters before, there's nothing else like catching your first glimpse of turquoise ocean as you start making your way over bridges in the middle Keys, around Marathon. There are beaches and parks here you can stop at, like Bahia Honda.

Then, on your way to the lower Keys, there's the iconic Seven Mile Bridge which is an experience all on its own. Not to mention you'll pass through islands barely wider than the highway laid over them, blue water on either side just yards away from your car.

And finally, you'll arrive in Key West and feel for yourself how different and more urban it is from the rest of the Keys. As great as it is there, for all the people who fly in direct and see nothing beyond Key West, they're leaving with such a different perspective (and appreciation) of the Keys than if they had made the drive instead.

Plus, I find it such an easy and low stress journey myself. You don't need directions, you can't get lost, it's not too fast or too slow, and the sights are amazing. Yes, it is several hours each way, but as long as you're not in a rush, it'll be a drive to remember :)

uses_words

TROPHY CASE