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Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

“doc, I Have 10/10 Pain!”


Pain control is one of the primary responsibilities of an emergency physician. At our disposable are a variety of medications and procedures (nerve blocks, etc) we use at our discretion based on the severity of pain, effectiveness of analgesia, time to administer, and side effects of the treatment.

As an alternative to traditional analegesia (acetaminophen, NSAIDs, opioids), a systematic review of the literature on low-dose ketamine, otherwise known as subdissociative dose ketamine (<1mg/kg), for analgesia was recently published on Academic Emergency Medicine. Most of us have used ketamine for procedural sedation and as an induction agent for its dissociative effects, but it is not often utilized for analgesia.

In the review, four studies (all RCTs) were reviewed with the primary outcome being change in pain score and the secondary outcome being occurrence of adverse events such as vomiting or dissociation. 2 of the 4 studies reported significant reductions in pain while 1 study other study reported lower pain scores without absolute numbers. 2 studies demonstrated a reduction in opiate use by patients. A pediatric study reported increased vomiting with ketamine although this was not reported in adult studies.

Since this review, there have been new studies published and others are in the works. For now, subdissociative ketamine may be an alternative to or for pain refractory to traditional analgesia, possibly even for an unstable, hypotensive patient you want to give analgesia to prior to cardioversion. One recent study (3) recommends 0.3mg/kg for optimal analgesia. However, future RCTs are needed to describe its efficacy and safety.

Academic EM systematic review:

1. http://onlinelibrary.wiley.com/doi/10.1111/acem.12705/full

New studies:

2. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial.

3. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.

My Head Hurts

35 y F presents to ED with sudden onset worst headache of life starting 3 hours ago.  Refractory to treatment with excedrin.  No history of Migraines.  Concern for SAH. What is your management algorithm to rule out SAH?  Do you CT/LP?

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Orthopedic Injuries

34 y M with right midfoot swelling and pain after injuring while playing football.  The patient describes a hyper-plantarflexion mechanism.  Physical exam notable for bruising to medial plantar foot and diffuse swelling to dorsal midfoot with tenderness to palpation.  XR is seen below:

Lisfranc No Arrows

What is the diagnosis?

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Exertional Syncope

23 y M presenting to ED with episode of syncope while playing soccer this afternoon.  Endorses preceding palpitations, but denies any associated CP/diaphoresis/n/v/sob.  EKG is as follows:


What is the diagnosis?

Continue reading “Exertional Syncope” »

A Different Approach to Central Line Placement

Today’s pearl comes to you directly from Dr. Reuben Strayer (emupdates.com) and I think is particularly applicable to resident learners.  The traditional teaching for CVC placement has involved needle puncture and stabilization of said needle followed by detaching the syringe and threading a wire.  Many, typically less experienced providers (i.e. residents), have a tendency to move the needle (even while attempting to keep it stable) while removing the ultrasound or while unscrewing the syringe.  This process often dislodges the needle making it impossible to threat the wire.  A technique that has been around for some time, but is underutilized, is the wire through catheter technique, which allows you to thread a catheter over the needle so that it remains stable inside the vein, rather than having to perform the more difficult task of stabilizing the needle.  The two techniques are demonstrated in the video attached to the link that follows.  Also, do not forget your confirmatory techniques, which are discussed in the video as well.  Without further ado, the soothing voice of Dr. Strayer.


Leslie Pendery, MD