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practice updates

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

Intranasal Analgesia

Being flexible and creative are important traits to have while working the ED. It is also vital to always keep the end result in mind. Pain control is always an important endpoint for us to constantly consider. While most of us would say that we strive alleviate our patients’ pain, there is evidence that we are not great at it. Thanks to Sean M. Fox, MD (@PedEMMorsels) for this great post!

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

Appendicitis Clinical Decision Rules

Often the Ped EM Morsels discuss diagnoses that emphasize astute clinical skills and vigilance while minimizing the importance of laboratory testing. Appendicitis is a great example of this! Thanks to Sean M. Fox, MD (@PedEMMorsels) for this great post!