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?

ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

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.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

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. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

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.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

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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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