Mid-Level Providers

Mid-Level Providers

Who they are, what they do, and why they’re changing emergency medicine

How to make sense of the puzzle and improve your practice.

When Patients Lie

When Patients Lie

How to Spot Deception, What You Can Do, and Why it Matters

Accusing anyone of lying is serious business, but when that person is your patient, the stakes are even higher. 

Raves and Saves

Raves and Saves

Advanced Emergency Management at Mass Gatherings

EM is crucial at drug-fueled electronic dance festivals, like this month’s Electric Zoo in New York.  

Transfusion Confusion

Transfusion Confusion

Knowing the Real Risks of Blood Transfusion

This routine procedure bears real risks and should be handled accordingly.

The ABCs (and T) of Rural EM

The ABCs (and T) of Rural EM

Situational Awareness is Key

When you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing…

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

DNR Means Do Not Treat . . . and Other End-of-Life Care Myths

Debunking 5 Fallacies

Improve your EOL care and communicate more effectively.

Through the Looking Glass

Through the Looking Glass

Three Novel Use Cases for Google Glass in the ED

How might augmented reality change your practice?

Augmented ED

Augmented ED

The future of emergency medicine?

EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications.

All About Metoclopramide (Reglan)

All About Metoclopramide (Reglan)

Know the risks

Reglan should be used with caution if patients have Parkinson’s disease or are on antipsychotics.

Physicians Won't Be Silenced

Physicians Won't Be Silenced

ACEP's Gag Order Rejected

EPM readers speak out against ACEP’s new ruling prohibiting incoming leaders from answering questions from non-ACEP publications.

Changemaker

Changemaker

How One EP Transformed Mental Health Admissions in Virginia

Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment.

Get the Gear Off

Get the Gear Off

Removing the Helmet and Pads is Crucial to Treating Spinal Injuries from Football

Up to 25% of c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.

The War on Death

The War on Death

by Greg Henry, MD

The guns and butter debate is really over, I guess.

How Do I Know if I'm Being Paid Fairly?

How Do I Know if I'm Being Paid Fairly?

Trust is key

I get paid based on my productivity, but I don't trust that my company is paying me accurately.

The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Understanding ACEP’s Clinical Policy on Seizures

Understanding ACEP’s Clinical Policy on Seizures

ACEP's 2014 Seizure Guidelines

A point-by-point review by Dr. Rhonda Cadena  

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Next to substance abuse, anxiety disorders are some of the most prevalent psychiatric conditions today with generalized anxiety disorder (GAD) having a lifetime prevalence of 5%. This disorder, which is more prevalent among women, often begins before age 25 and has a low rate of remission without treatment. The American Psychiatric Association established a diagnostic criteria for GAD that includes: excessive anxiety/worry occurring more days than not for at least 6 months; difficulty controlling worrying; anxiety/worry that isn’t confined to features of other psychiatric disorders; mental or physical symptoms that cause significant distress or impairment in important areas of function, and symptoms that are not the physiologic effect of a medicine or another organic disease process. Also the anxiety/worry must be associated with at least three of the following six symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Patients at risk include those with a family history, increased stress, and previous physical or emotional trauma. GAD has also been associated with heavy smokers and certain medical illnesses such as diabetes.

To make this diagnosis, other medical disorders, drug use (cocaine, amphetamines) or withdrawal, and recent changes in prescribed (corticosteroids) or OTC medicines (ginseng, caffeine) need to be ruled out. There are clues you can spot that suggest that anxiety is a symptom (as opposed to the clinical disorder). These clues include onset after 35, no previous history of anxiety, little change in life stressors, patients do not try to avoid anxiety-provoking situations, and a poor response to pharmacologic therapy. No specific recommendations can be made regarding laboratory evaluation aside from the possible helpfulness of thyroid evaluation as there is a high prevalence of GAD in patients suffering from hyperthyroidism. What also makes this disease difficult to diagnose is that is often occurs alongside other psychiatric conditions. The most common is major depression which occurs in two out of three patients with GAD. Panic disorder (recurrent attacks followed by one month of anxiety over concern of future attacks) and alcohol abuse also have a high incidence in this population.

Once the diagnosis of GAD has been established, there are many therapies to consider. In general the practitioner must remember that many of these therapies take at least 4 weeks to have an effect, are associated with many side effects, require close supervision including increases and weans of the medications, can be associated with abuse and withdrawal (benzodiazepines), and the need to treat concomitant substance abuse. As these treatments can take time to work, one should be cautious about starting them in the ED. TCAs including imipramine and nortriptyline should be started at half the usual dose. These drugs are well known to have many side effects including arrhythmias, tachycardia, orthostasis, weight gain, and anticholinergic effects. Also, they can be lethal in overdose.

SSRIs have become very popular as they are equally as efficacious as TCAs but have less severe side effects. As restlessness can occur with drug initiation, starting doses should be low. Paroxetine does have FDA approval for the treatment of GAD. While the initiation of SSRIs does mandate monitoring for suicidal ideation, current reviews including nearly 50,000 patients did not show an increased rate in placebo-controlled studies. SSRIs include citalopram, escitalopram, paroxetine, and sertraline. Side effects include nausea, vomiting, diarrhea, dry mouth, and sexual dysfunction. Venlafaxine, an SNRI, is a closely related medication that also has FDA approval for GAD. Side effects of this drug include systolic hypertension and conduction defects and ventricular arrhythmias as well as many of the same side effects from SSRIs.

Other options include buspirone, anticonvulsants (gabapentin and tiagabine), and benzodiazepines. Buspirone is a nonbenzodiazepine anxiolytic. While it has several advantages including not causing sedation, physical dependency, or withdrawal, it does not have an antidepressant effect and can take 4 weeks to have a therapeutic effect. While benzodiazepines have been shown to be effective within 2 weeks, they were the least effective medication by 8 weeks and are addictive.

Pregnant or postpartum women deserve special attention as they are at an increased risk. Buspirone may be safe during pregnancy, but benzodiazepines should probably be avoided due to defects in first and third trimesters as well as sedation effects seen in breast feeding. While SSRIs appear not to be teratogenic, there have been reports of neonatal toxicity, early delivery, and respiratory distress with particular concern for paroxetine use near delivery. Use of the lowest effective dose is advised during pregnancy and lactation. 
 

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