Bell’s Palsy and Burns


We are in Las Vegas at ACEP 2016 thanks to Annals of Emergency Medicine and ACEPnow and discuss high yield and cutting edge lectures each day.

Dr. Megan Osborn – Bell’s Palsy or Stroke?

Traditional teaching: we can differentiate Bell’s palsy (lower motor neuron) from a stroke (upper motor neuron by assessing forehead involvement.  If the patient can wrinkle their forehead? Think stroke.  Dr. Megan Osborn tackled the question: does this actually work all the time in her talk in the New Speakers Forum.


Dr. Toree McGowan – Burns

Check out this podcast for more on burns


  1. Sherman SC, Thompson TM, Thompson TT. Pontine hemorrhage presenting as an isolated facial nerve palsy. Annals of emergency medicine. 46(1):64-6. 2005. [pubmed]
  2. AAN Bell’s Palsy Guideline Update
  3. Fahimi J, Navi BB, Kamel H. Potential Misdiagnoses of Bell’s Palsy in the Emergency Department. Annals of Emergency Medicine. 63(4):428-434. 2014. [article]
  4. Madhok VB, Gagyor I, Daly F. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). The Cochrane database of systematic reviews. 7:CD001942. 2016. [pubmed]
  5. Gagyor I, Madhok VB, Daly F. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). The Cochrane database of systematic reviews. 2015. [pubmed]
  6. Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. The Cochrane database of systematic reviews. 2008. [pubmed]
  7. Ringh M, Rosenqvist M, Hollenberg J et al. Mobile-Phone Dispatch of Laypersons for CPR in Out-of-Hospital Cardiac Arrest. N Engl J Med. 372(24):2316-2325. 2015. [article]

Vaccine Side Effects and Placebos


We are in Las Vegas at ACEP 2016 thanks to Annals of Emergency Medicine and ACEPNOW and discuss high yield or cutting edge lectures each day.

Dr. Matthew DeLaney – 21st Century Snake Oil (Placebos)



Dr. Al Sachetti – Immunization Reactions in the Emergency Department

check out the WHO fact sheets


Dr. Corey Slovis – Atrial Fibrillation



  1. Llor C, Moragas A, Bayona C. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ (Clinical research ed.). 347:f5762. 2013. [pubmed]
  2.  Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922
  3. Dobson R. Cough medicines’ effect is mainly placebo. BMJ. 2006 Jan 7; 332(7532): 8. PMCID: PMC1325161
  4. Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; PMID:22869830
  5. Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Annals of emergency medicine. 64(5):526-532.e1. 2014. [pubmed]
  6. Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. The Cochrane database of systematic reviews. 2015. [pubmed]
  7. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 68(1):1-9.e1. 2016. [pubmed]
  8.  Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. [pubmed]
  9. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. The Cochrane database of systematic reviews. 4:CD007400. 2016. [pubmed]
  10. Silberban. Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why.

The Transgender Patient + more from ACEP

Listen Here or iTunes

We are in Las Vegas at ACEP 2016 and discuss high yield or cutting edge lectures each day.

Dr. Anne Daul – Emergency Care of the Transgender Patient

Most emergency medicine physicians and trainees lack training in caring for LGBTQ patients, let alone transgender patients [1].  Many members of the LGBTQ community may have delays in medical care including 21% of transgender patients in a Canadian survey[2].  Also, according to a 2010 task force, 19% of transgender patients report being denied care in some way [3].


Here is a video from SMACC Dublin from Thom O’Neill on caring for LGBT youth

Check out these FOAM resources from EPMonthly and Mayo.

Dr. David Callaway – Active Shooter

2% of active shooter events take place in the health care setting.

Plan of Action in Active Shooter Scenario: AVOID DENY DEFEND TREAT

  • Avoid – stay away from the shooter.
  • Deny – deny them access to you or the area. Lock doors, block pathways, turn off the lights, make it more difficult for them.
  • Defend -.if necessary, defend yourself.
  • Treat – once you are safe, and the scene is safe, treat and care for your patients.

Dr. Kevin Klaur – Lawsuits

Documentation and discharge instructions repeatedly come up in lawsuits.

  • Documentation: If you document after the fact, particularly if there was a bad outcome – be straightforward that you are documenting after the fact. Do not document as though you do now know the outcome
  • Discharge – lawsuits often come up because discharge instructions or documentation were not sufficient. Klauer argues that it is not sufficient to state “patient improved, discharged home.” He urges us to document a repeat exam or show HOW they are improved.

Dr. Klauer also gave some general pearls on lawsuits – high numbers for orthopedics/missed fractures and administration of RhoGham.  An additional pearl he gave was for cauda equina.

  • These patients often have small post void residuals because it’s a neurogenic problem, not a mechanical obstruction.  Thus, if a patient has other features and has a post void residual of 100 cc, it’s not necessarily not cauda equina.


One ACEP16 lecturer talked about magnesium use in alcohol withdrawal – probably not ready for prime time, Cochrane agrees  [4].


  1. Moll J, Krieger P, Moreno-Walton L. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 21(5):608-11. 2014. [pubmed]
  2. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine. 63(6):713-20.e1. 2014. [pubmed]
  3. Grant JM, Mottet LA, Tanis JD et al. National Transgender Discrimination Survey Report on health and health care Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force.  October 2010
  4. Tejani SM. Magnesium for the prevention or treatment of alcohol withdrawal syndrome in adults. June 2013

Episode 58 – Ophthalmology

The Free Open Access Medical Education (FOAM) 

Listen Here or iTunes

We cover an incredible ophthalmology resource,, by Dr. Tim Roots.  This resource has a free book and excellent free video lectures.  Specifically, we detail a hilarious video on eye exam tricks, especially targeting individuals who “can’t see.”

ReasonExam Trick 
"Can't See"Optokinetic DrumEyes track movement in a non-voluntary way and results in pursuit, sacchade. Vision is at least 20/200 if they can do this
"Can't See"Stick out your hand as if to shake theirsOften a habit to reflexively reach out
"Can't See"Have the patient touch their index fingers together in front of them.This is a test of proprioception so if they are unable to do this, they either have a problem with proprioception or are faking.
Visual Field or Possible NeglectHold a pen horizontally in front of the patient's face and ask them to point to midline.If the patient points off of midline, this suggests a visual field deficit
  • Core Content
  • We previously reviewed eye trauma in this podcast. In this episode, we review ophthalmology basics using Tiintinalli’s Emergency Medicine Chapter 241.
  • screen-shot-2016-10-09-at-5-22-35-pm

When doing the pupillary exam, it is important to assess for an afferent pupillary defect (APD). Ophthalmologists will want “there is or is NOT an APD” when you consult them for essentially any reason.  Normal pupils constrict when the light is shown in either pupil (direct and consensual constriction). To assess for an APD, perform the “swinging light test.”


Causes: optic nerve pathology (ex: optic neuritis) or occsaionally, retinal pathology (CRAO)


Peer reviewed by Michael Westafer, MD ophthalmologist and glaucoma fellow at Cleveland Clinic.

Generously Donated Rosh Review Questions

A 72-year-old man presents with a painful red eye and visual loss worsening over the last 24 hours. He recently had cataract surgery. Examination of the eye reveals the image above. Which of the following is the most likely?

A. Endophthalmitis

B. Hyphema

C. Uveitis

D. Vitreous hemorrhage


A. Endophthalmitis is an infection involving the anterior, posterior and vitreous chambers of the eye. It results from trauma (blunt globe rupture, penetrating injury, foreign bodies) and alsoiatrogenically after ocular surgery like cataract repair. Patients complain of severe pain in the eye and visual impairment or loss. Examination of the eye reveals decreased visual acuity, injected conjunctiva, chemosis and haziness of the infected chambers. Infections are treated with both systemic and intraocular antibiotics.

A hyphema (B) is blood in the anterior chamber usually caused by trauma. When the patient is in an upright position, blood will layer along the inferior aspect of the anterior chamber. As the hyphema increases in size, it elevates intraocular pressure. In some cases admission is warranted for patients with large hyphemas (>50%), decreased vision, sickle cell disease and elevated intraocular pressure. Treatment is aimed at decreasing pressure with topical (beta-blocker, alpha agonist or carbonic anhydrase inhibitors) and systemic therapy (carbonic anhydrase inhibitor, mannitol). Uveitis (C) occurs after blunt trauma in which the iris and ciliary body are inflamed causing ciliary spasm. Patients complain of significant photophobia with significant eye pain. Examination of the eye reveals perilimbal conjunctival injection (also called ciliary flush) and a small, poorly dilating pupil. Photophobia occurs with light shone on both the affected and unaffected eye. On slit lamp, cells (white and red) and flare (protein) are noted in the anterior chamber. Treatment is with a topical cycloplegic agent to minimize spasm. Vitreous hemorrhage (D) occurs as a result of injuries to the retina, uveal tract and their associated vascular structures. Common associated conditions include diabetic retinopathy, retinal vein occlusion and trauma. Patients complain of decreased visual acuity and floaters. The condition is not typically painful. Diagnosis is made with ocular ultrasound showing blood products in the posterior chamber.

What is a dependent pocket of pus seen in the anterior chamber called?

  • Answer
  • Hypopyon.