Welcome to The Pearl Log — where post-shift wisdom surfaces, one shiny clinical take at a time. Some pearls are fresh, some are rough, all are found under pressure.
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Pain Management in OUD
A patient with opioid use disorder has the same right to effective acute pain control as anyone else. Continue buprenorphine during acute pain, use multimodal analgesia, and add full-agonist opioids when clinically indicated—often with higher doses needed because of opioid tolerance. For patients on buprenorphine, fentanyl or hydromorphone are preferred because of their higher μ-receptor affinity. Appropriate opioid treatment for acute pain has not been shown to destabilize OUD and undertreated pain may itself contribute to worse outcomes.
The BP Is 200. Everybody Stay Calm.
A high blood pressure reading doesn’t always need treatment—and hydralazine probably isn’t the answer. A quick look at updated AHA and ACEP guidance on asymptomatic hypertension, hypertensive emergencies, and practical options for starting long-term therapy from the ED.
Traumatic dental injury, Pip-Tazo and AKI, and Infected Nephrolithiasis
Need to know traumatic dental emergencies, Pip-Tazo isn’t as bad as you were told, and the clinical picture is key for that kidney stone with a concerning UA.
ED Workflow: A Cognitive Framework
The ED can be intense. Here’s a workflow to help you make the best of your shift.
Sinus Node Dysfunction and some other stuff.
A case of sinus node dysfunction. Brief commentary on syncope and PE, cellulitis, and isotonic bicarb in hyperkalemia.
Deep Dive: ED Hip Fracture Management
A practical review of ED management of hip fractures, including high-yield bedside pearls, occult fractures, peripheral nerve blocks, and communicating with orthopedics. It also takes a closer look at the evidence behind preoperative Buck's traction and what current guidelines recommend.
Tizanidine Overdose and Hyperemesis Gravidarum
A brief discussion on tizanidine overdose management and hyperemesis gravidarum.
Quick Hits: Airway update, headache guidelines, status epilepticus, nailbed repair, and shellfish allergies.
Several topics we discussed on shift, including evidence-based airway management, rapid treatment of status epilepticus, nail bed injury management after the NINJA trial, contemporary migraine therapy, and the persistent myth surrounding shellfish allergy and iodinated contrast. As always, these are meant to be quick introductions to practice-changing literature and resources that are worth a closer look.
Chest Pain, Anticoagulated Falls, and Bug Bites
Explore how prevalence shapes chest pain risk, why CT decisions in anticoagulated falls remain an evidence gap, and how large local allergic reactions can convincingly masquerade as cellulitis.
Enough is Enough. Routine Coags in the ED.
Routine coags in low-risk ED patients rarely change management and often create downstream problems instead.
Aortas, Rectums, and BPPV
A little bit on suprasternal notch view for aortic dissection, the importance of the digital rectal exam for perirectal abscess diagnosis, and a referral to a new BPPV review article.
Leg Pain Pontification
Osteoarthritis is a clinical diagnosis driven by multifactorial structural and central pain mechanisms, where symptom severity often poorly correlates with imaging, and management remains stepwise with a focus on nonpharmacologic therapy and, if needed, topical NSAIDs. For suspected DVT, a structured approach using Wells criteria and age-adjusted D-dimer safely reduces unnecessary imaging, with recent prospective data supporting its reliability in low- to moderate-risk patients.
Knee Pain and Monkeypox
Throw out those knee immobilizers for traumatic knee pain.
Don’t miss monkeypox when it walks into your ER!
Quickhits: Whole Blood In Trauma, Triple Negative Breast Cancer, and the Linear Probe for IUP
Whole blood for trauma, triple negative breast cancer, and ultrasound for IUP identification.
Early Pregnancy Loss in the Emergency Department
Early pregnancy loss is common and requires careful diagnosis using strict ultrasound criteria before confirming nonviability. Stable patients should be offered all three management options—expectant, medical, and procedural—with medical therapy using mifepristone and misoprostol as an effective, evidence-based approach. Most cases can be managed with clinical follow-up rather than routine imaging, with clear return precautions and patient-centered counseling guiding safe disposition.
2026 AHA Guideline on Acute Pulmonary Embolism
The 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for Evaluation and Management of Acute Pulmonary Embolism. A brief ED focused summary.
Post Cardiac Arrest Management
The AHA has put out a bunch of recent statements and guidelines regarding post cardiac arrest care. Take a look at these to up your game!