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Intern Report Collection, Vol. 6

To kick off your weekend reading pleasure, here’s another batch of excellent write-ups from the EM interns at UT Southwestern (@DallasEMed) courtesy of Alex Koyfman (@EMHighAK) . Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

practice updates

The Art of the ED Takedown

The ED patient is often times acutely agitated, violent or psychotic and a danger to themselves and those around them. The ED takedown is a useful skillset comprised of physical restraint and chemical sedation, which can be implemented in the management of these challenging patients. Prior to using physical restraints or chemical sedation, identifying the cause of agitation and using verbal de-escalation techniques should always be prioritized. Physical restraints are generally safe to use if done properly as a team effort. The decision to use chemical sedation should take into the consideration the type of patient (adult, child, elderly), the cause of agitation (anxiety, psychosis, organic reason) and potentially detrimental side effects. o Benzodiazepines are good choices in many adult patients due to their rapid onset of action and short duration of action, however, they should be avoided in elderly patients due to risk of respiratory depression and somnolence. o Typical antipsychotics , such as Droperidol, are safe to use in low doses, however providers should be on the lookout for very rare cases of QT prolongation. o Atypical antipsychotics are also a favorable choice given the lower incidence of EPS and somnolence, however there is an associated risk of dementia-related psychosis in the elderly population. o Ketamine is a common favorite in the ED and has a broad spectrum of use in both adult and pediatric patient populations, however there is a very low risk of laryngospasm and worsening of symptoms in psychotic patients. o Different combination therapies can be considered depending on the specific patient and physician preference.

practice updates

Lyceum Bullets: Trauma

Questions addressed by EM Lyceum and bulleted by emDocs: 1. When do you use tranexamic acid in trauma? 2. When you can’t get peripheral access in a trauma patient, do you prefer subclavian, femoral, or IO? 3. Which trauma patients do you give PCC to over FFP? 4. In blunt abdominal/flank trauma, do you send a urinalysis or simply look for gross hematuria?

practice updates

Intern Report Collection, Vol. 5

Our ongoing intern report series is the product of first-year EM residents at UT Southwestern exploring clinical questions they have found to be particularly intriguing. For med students & junior residents – if you haven’t encountered these issues yet, you will!


The Hypotensive ED Patient: A Sequential Systematic Approach

Treat the patient, not the number. A blood pressure of 120/80 mmHg in a chronically hypertensive patient can be dangerously low. Whatever the HPI may suggest, unbiased implementation of the bedside physical examination and sonography are crucial in the workup of unexplained hypotension. This four step systematic approach of sequentially assessing heart rate, volume status, cardiac performance, and systemic vascular resistance can narrow the differential and guide management.