ALiEM Cards is point-of-care reference library of narrowly focused, easily digestible cards for the practicing emergency physician or learner (formerly known as PV Cards). As of July 2017 led by the team of Dr. Jeremy Voros and Derek Sifford, we have rebranded these into “ALiEM Cards”.

Index of Topics

Topic	PDF	Major Subject	Minor Subject	Blog page	Date
Abdominal pain, diagnostic studies	PDF	Surgery, trauma	Diagnostics	Blog	2011/07/22
Abdominal trauma, blunt (likelihood ratios)	PDF	Surgery, trauma	Bayes	Blog	2012/04/20
Abdominal trauma, penetrating	PDF	Surgery, trauma		Blog	2010/07/09
ABG interpretation	PDF	Pulmonary, critical care	Diagnostics	Blog	2010/04/02
Acetaminophen toxicity	PDF	Toxicology, pharmacology		Blog	2011/11/04
Acute limb ischemia	PDF	Cardiovascular		Blog	2010/08/13
Acute vestibular syndrome and HINTS exam	PDF	Neurology		Blog	2011/12/02
Alcohol: Ethylene glycol	PDF	Toxicology, pharmacology		Blog	2012/06/08
Alcohol: Isopropyl alcohol	PDF	Toxicology, pharmacology		Blog	2012/06/22
Alcohol: Methanol	PDF	Toxicology, pharmacology		Blog	2012/06/15
Anaphylaxis	PDF	Allergy, Immunology		Blog	2012/02/24
Angioedema	PDF	Allergy, Immunology		Blog	2010/03/26
Ankle and Hindfoot Fractures	PDF	Orthopedics		Blog	2016/06/06
Ankle fractures	PDF	Orthopedics		Blog	2010/02/18
Anticoagulation for atrial fibrillation	PDF	Cardiovascular		Blog	2010/04/09
Aortic dissection (IRAD)	PDF	Cardiovascular		Blog	2011/05/20
Appendicitis: ACEP clinical policy	PDF	Surgery, trauma		Blog	2010/06/18
Asthma NIH classifications	PDF	Pulmonary, critical care		Blog	2011/04/29
Bayes nomogram	PDF		Bayes		2012/05/17
Bell’s Palsy: Treatment	PDF	Neurology		Blog	2013/02/21
Blood culture indications	PDF	Infectious disease	Bayes	Blog	2012/08/17
Blunt cardiac injury	PDF	Surgery, trauma		Blog	2012/06/29
Brugada syndrome	PDF	Cardiovascular		Blog	2011/05/06
Burns	PDF	Surgery, trauma		Blog	2016/04/22 update (original 7/2/2010)
C1-C2 fractures	PDF	Orthopedics		Blog	2010/09/24
C3-C7 fractures	PDF	Orthopedics		Blog	2010/10/01
Cardiac tamponade	PDF	Cardiovascular	Bayes	Blog	2011/07/08
Cerebrovascular injury, blunt	PDF	Surgery, trauma		Blog	2011/07/01
Cervical spine rules	PDF	Surgery, trauma		Blog	2010/12/10
Cervical spine, distracting injury	PDF	Surgery, trauma		Blog	2011/09/09
Charting and Coding	PDF	Administrative		Blog	2016/08/15
Chemical sedation	PDF	Toxicology, pharmacology		Blog	2011/03/25
Chest pain, low risk ACS	PDF	Cardiovascular		Blog	2010/01/29
CHF likelihood ratios	PDF	Cardiovascular	Bayes	Blog	2012/08/24
Cholecystitis tests	PDF	Surgery, trauma	Bayes	Blog	2011/03/18
Clostridium difficile	PDF	Infectious disease		Blog	2011/06/24
CNS infections	PDF	Neurology		Blog	2009/12/29
Continuous end tidal CO2 monitoring in cardiac arrest	PDF	Pulmonary, Critical Care		Blog	2015/10/20
Continuous infusions	PDF	Toxicology, pharmacology		Blog	2012/03/09
Croup	PDF	Pediatrics		Blog	2010/08/20
CT cancer risk	PDF	Radiology		Blog	2011/06/10
Cystitis/Pyelonephritis Women Antibiotics	PDF	Genitourinary		Blog	2011/09/02
D-dimer	PDF	Hematology, oncology	Diagnostics	Blog	2012/07/12
Delayed sequence intubation	PDF	Airway, pulmonary		Blog	2012/08/31
Dental infections	PDF	ENT		Blog	2011/04/22
Dental trauma	PDF	ENT		Blog	2011/04/15
Dermatomes and myotomes	PDF	Neurology	Anatomy	Blog	2010/05/28
Diabetic foot osteomyelitis	PDF	Orthopedics	Bayes	Blog	2011/09/23
Diverticulitis outpatient	PDF	Surgery, trauma		Blog	2011/05/27
Drug Card Emergency Department	PDF	Toxicology, pharmacology		Blog	2013/09/11
DVT Diagnostic Guidelines (ACCP)	PDF	Cardiovascular		Blog	2013/01/24
Dysphagia	PDF	ENT		Blog	2010/02/03
Early goal directed therapy in sepsis	PDF	Infectious disease		Blog	2010/04/16
ECG: Early repolarization vs STEMI	PDF	Cardiovascular		Blog	2013/05/16
ECG: Electrolyte imbalance	PDF	Cardiovascular, Endocrine		Blog	2012/09/21
ECG: Geography of AMI	PDF	Cardiovascular	Diagnostic	Blog	2011/04/08
ECG: Lead aVR	PDF	Cardiovascular	Diagnostic	Blog	2011/11/18
ECG: Right and posterior leads	PDF	Cardiovascular	Diagnostic	Blog	2011/03/11
Ectopic Pregnancy	PDF	Obstetrics/gynecology	Bayes	Blog	2013/05/09
EMTALA rules in the transfer of ED patients	PDF	Administrative		Blog	2012/09/14
Genital ulcers	PDF	Genitourinary		Blog	2012/05/04
GRACE score	PDF	Cardiovascular		Blog	2012/04/13
Head CT before LP	PDF	Neurology		Blog	2010/04/23
Head CT in trauma: Decision rules	PDF	Surgery, trauma		Blog	2011/05/13
Hyperkalemia	PDF	Endocrine, metabolic		Blog	2010/03/12
Hypertension: First line treatment	PDF	Cardiovascular		Blog	2011/02/11
Hypothermia, accidental	PDF	Environmental		Blog	2011/02/04
Influenza treatment	PDF	Infectious disease		Blog	2011/10/28
Intimate partner violence	PDF	Trauma		Blog	2013/07/31
Intraosseous lab interpretation	PDF	Hematology, oncology	Diagnostics	Blog	2012/01/13
IV fluid composition and Chloride-restrictive fluids in ICU	PDF	Endocrine, metabolic		Blog	2012/01/03
Kawasaki disease	PDF		Pediatrics	Blog	2012/03/23
Knee exam	PDF	Orthopedics		Blog	2010/03/19
Laceration repair and sutures	PDF	Trauma		Blog	2017/03/06
Legionnaires disease	PDF	Pulmonary, critical care		Blog	2011/09/16
Local anesthetic toxicity	PDF	Toxicology, pharmacology		Blog	2014/06/13
Metacarpal fracture	PDF	Orthopedics		Blog	2013/12/13
Methotrexate and ectopic pregnancy	PDF	Gynecology, obstetrics		Blog	2011/11/11
Murmurs and need for echocardiography	PDF	Cardiovascular		Blog	2010/09/17
Neutropenic fever and cancer	PDF	Infectious disease		Blog	2011/10/07
NSAID bleeding risk	PDF	Toxicology, pharmacology		Blog	2011/07/15
One minute preceptor: NERDS mnemonic	PDF	Education		Blog	2015/08/01
Open fractures and antibiotics	PDF	Orthopedics		Blog	2012/01/20
Osmolal gap	PDF	Toxicology, pharmacology		Blog	2012/06/01
Ottawa knee, ankle, foot rules	PDF	Orthopedics		Blog	2010/05/07
Overanticoagulation and supratherapeutic INR	PDF	Hematology, oncology		Blog	2012/08/10
Pain medications: Initial options in the ED	PDF	Toxicology		Blog	2015/10/23
Palliative Care Screening in the ED	PDF	Palliative Care		Blog	2015/07/27
Paracentesis and ascites assessment	PDF	Gastroenterology		Blog	2010/06/25
PE clinical decision rules	PDF	Pulmonary, critical care		Blog	2011/06/03
PE indications for fibrinolysis	PDF	Pulmonary, critical care		Blog	2011/07/29
Pediatric assessment triangle	PDF	Pediatrics		Blog	2013/05/30
Pediatric fever (1-3 months old)	PDF	Infectious disease	Pediatrics	Blog	2012/02/02
Pediatric fever (3 mo- 3 yrs old)	PDF	Infectious disease	Pediatrics	Blog	2012/02/09
Pediatric fever (neonate)	PDF	Infectious disease	Pediatrics	Blog	2012/01/27
Pediatric head trauma (PECARN)	PDF	Surgery, trauma	Pediatrics	Blog	2010/02/04
Pediatric ingestion dose thresholds for ED referral	PDF	Toxicology, pharmacology	Pediatrics	Blog	2014/07/09
Pediatric pertussis algorithm	PDF	Pulmonary, critical care	Pediatrics	Blog	2010/10/29
Pediatric sizes and doses	PDF		Pediatrics	Blog	2010/10/23
Pericarditis	PDF	Cardiovascular		Blog	2015/02/05
Pertussis	PDF	Pulmonary, critical care	Bayes	Blog	2010/09/03
PESI score for pulmonary embolism	PDF	Pulmonary, critical care		Blog	2012/11/17
Pneumonia scores	PDF	Pulmonary, critical care		Blog	2011/02/25
Post-exposure prophylaxis, non-occup	PDF	Infectious disease		Blog	2011/04/01
Procedural sedation	PDF	Toxicology, pharmacology		Blog	2010/08/06
Rapid sequence intubation	PDF	Toxicology, pharmacology		Blog	2010/07/16
Rashes, approach to	PDF	Dermatology		Blog	2011/08/26
Red eye	PDF	Ophthalmology		Blog	2010/01/22
Salicylate toxicity	PDF	Toxicology, pharmacology		Blog	2015/06/15
Scaphoid fracture	PDF	Orthopedics		Blog	2016/02/01
Seizure, first time	PDF	Neurology		Blog	2011/01/13
Seizure, status epilepticus	PDF	Neurology		Blog	2011/01/20
Septic arthritis	PDF	Orthopedics	Bayes	Blog	2010/06/11
Serotonin syndrome	PDF	Toxicology, pharmacology		Blog	2012/01/06
Sgarbossa criteria for LBBB	PDF	Cardiovascular	Bayes	Blog	2010/11/05
Shift feedback card	PDF	Education		Blog	2011/12/09
Shock and RUSH protocol	PDF	Cardiovascular		Blog	2009/12/22
Shock, vasopressors and inotropes	PDF	Cardiovascular		Blog	2010/04/30
Shoulder exam	PDF	Orthopedics		Blog	2011/01/28
Spinal epidural abscess	PDF	Neurology		Blog	2011/08/05
Streptococcal pharyngitis	PDF	ENT		Blog	2010/07/30
Stroke scale NIH	PDF	Neurology		Blog	2010/02/26
Stroke: Contraindications for Thrombolytics	PDF	Neurology		Blog	2013/05/23
Subarachnoid hemorrhage, atraumatic	PDF	Neurology		Blog	2010/03/05
Subarachnoid hemorrhage, high risk	PDF	Neurology		Blog	2010/12/17
Suicide risk stratification	PDF	Psychiatry		Blog	2011/02/18
Supraventricular Tachycardia (SVT) Aberrancy vs Ventricular Tachycardia (VT): Brugada Criteria	PDF	Cardiovascular		Blog	2013/02/27
Suture materials	PDF	Surgery, trauma		Blog	2011/01/07
Tachycardia, approach to	PDF	Cardiovascular		Blog	2011/08/19
TIMI score	PDF	Cardiovascular		Blog	2010/08/27
Toxidromes and vital signs	PDF	Toxicology, pharmacology		Blog	2010/11/19
Transient ischemic attack (TIA)	PDF	Neurology		Blog	2010/01/05
Ultrasound: 1st Trimester Pregnancy (Transabdominal)	PDF	Gynceology, obstetrics		Blog	2015/02/25
Ultrasound: 1st Trimester Pregnancy (Transvaginal)	PDF	Gynceology, obstetrics		Blog	2015/03/04
Ultrasound: Abdominal Aorta	PDF	Radiology		Blog	2014/09/13
Ultrasound: Biliary Exam	PDF	Gastroenterology		Blog	2015/01/01
Ultrasound: Deep Vein Thrombosis (DVT)	PDF	Cardiovascular		Blog	2015/02/18
Ultrasound: FAST	PDF	Radiology		Blog	2014/09/14
Ultrasound: Focused Echocardiography	PDF	Cardiovascular		Blog	2015/02/11
Ultrasound: Lung Exam	PDF	Pulmonary, critical care		Blog	2015/02/04
Ultrasound Measurements: Normal Values	PDF	Radiology	Ultrasound	Blog	2015/10/15
Ultrasound: Ocular Exam	PDF	Ophthalmology		Blog	2015/01/28
Ultrasound: Skin and Soft Tissue	PDF	Dermatology		Blog	2015/01/07
Ultrasound: Testicular Exam	PDF	Genitourinary		Blog	2015/01/21
Upper GI bleed	PDF	Gastroenterology	Bayes	Blog	2011/06/17
Urine toxicology	PDF	Toxicology, pharmacology	Diagnostic	Blog	2010/07/22
UTI, cystitis	PDF	Genitourinary		Blog	2010/02/11
VBG versus ABG	PDF	Pulmonary, critical care		Blog	2013/01/31
Ventilator settings: Lung protection	PDF	Pulmonary, critical care		Blog	2011/10/14
Ventilator settings: Obstructive disease	PDF	Pulmonary, critical care		Blog	2011/10/21

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Paucis Verbis: NSAIDS and upper GI bleeds

Do no harm.

We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year?

Ketorolac has the highest upper GI complication RR (14.54) for all of the studied NSAIDs. Compare this with the overall risk of traditional COX-1 NSAIDS (RR=4.5) and COX-2 inhibitors (RR=1.88). So before giving ketorolac, first check that patients don’t have a history of a GI bleed or peptic ulcer.

PV Card: NSAIDs and Upper GI Bleed

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Massó G, Patrignani P, Tacconelli S, García R. Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding. Arthritis Rheum. 2010;62(6):1592-1601. [PubMed]

By Michelle Lin, MD|2021-10-12T16:27:37-07:00Jul 15, 2011|ALiEM Cards, Gastrointestinal, Tox & Medications|

Paucis Verbis: Cardiac tamponade or just an effusion?

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer

Poor to average, at best. The Beck’s triad of hypotension, distended neck veins, and muffled heart sounds are important to remember … only on tests.

Think about performing a pulsus paradoxus test to see if it’s >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

PV Card: Cardiac Tamponade

Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Refrence

Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810. doi: 10.1001/jama.297.16.1810

By Michelle Lin, MD|2021-10-13T08:35:56-07:00Jul 8, 2011|ALiEM Cards, Cardiovascular, Ultrasound|

Paucis Verbis: Blunt cerebrovascular injuries

In the setting of blunt trauma, it is easily to overlook a patient’s risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.

Who are at risk for these injuries?
What kind of imaging should I order to rule these injuries out?
Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA?

FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.

PV Card: Imaging for Blunt Cerebrovascular Injuries

Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.

References

Burlew C, Biffl W. Imaging for blunt carotid and vertebral artery injuries. Surg Clin North Am. 2011;91(1):217-231. [PubMed]
Paulus E, Fabian T, Savage S, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 2014;76(2):279-83; discussion 284-5. [PubMed]
Bruns B, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg. 2014;76(3):691-695. [PubMed]

By Michelle Lin, MD|2021-10-13T08:38:34-07:00Jul 1, 2011|ALiEM Cards, Cardiovascular, Radiology, Trauma|

Paucis Verbis: Clostridium Difficile

I just finished taking the 2011 LLSA exam to remain eligible for recertification. The only good thing about this test is that it gives me interesting topics for my Paucis Verbis cards.

Here’s a card on a disease process that is becoming increasingly prevalent — Clostridium difficile. This is a summary based on the 2010 guidelines by Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).

Because healthcare workers are often the culprit for transmitting C. difficile to other patients, be sure you wash your hands with soap and water really well. Wear gloves. Be aware that alcohol-based hand rubs (eg. hand sanitizers) are ineffective in killing C. difficile spores.

PV Card: Clostridium Difficile Infection

Reference

Cohen S, Gerding D, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455. [PubMed]

By Michelle Lin, MD|2021-10-13T08:41:07-07:00Jun 24, 2011|ALiEM Cards, Gastrointestinal, Infectious Disease|

Paucis Verbis: Lifetime attributable risk of cancer from CT

How great would it be if you could give patients concrete numbers when you are talking about cancer risk and CT? Well, Dr. Hans Rosenberg (Univ of Ottawa) has come up with just such a table.

Using this table you can say that the risk is about “one in …”

PV Card: Cancer Risk from CT

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Smith-Bindman R. Radiation Dose Associated With Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer. Archives of Internal Medicine. 2009;169(22):2078. doi: 10.1001/archinternmed.2009.427

By Michelle Lin, MD|2021-10-13T08:43:55-07:00Jun 10, 2011|ALiEM Cards, Radiology|

Paucis Verbis: Pulmonary Embolism Clinical Prediction Rules

“Should I get a D-Dimer test or CT chest angiogram on my patient with atypical chest pain to rule-out a pulmonary embolism?” This is a common question asked by emergency physicians on a routine basis.

Here are 3 clinical prediction rules: PERC, Wells, and Simplified Geneva Score. Personally, I’ve never used the Geneva Score, but it’s worth looking at.

A WORD of CAUTION

These rules should be used with caution, because none of these scoring protocols are perfect. For instance, in a recent publication in the Journal of Thrombosis and Haemostasis, the authors found that the PERC rule does not actually safely exclude PEs.¹ Big bummer for us clinicians.

PV Card: Pulmonary Embolism Clinical Prediction Rules

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Kit Tainter (Mount Sinai PGY-4 EM resident) for coming up with the idea for this card!

Reference

Hugli O, Righini M, Le G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9(2):300-304. [PubMed]

By Michelle Lin, MD|2021-10-13T08:47:00-07:00Jun 3, 2011|ALiEM Cards, Pulmonary|

Paucis Verbis: Outpatient treatment for diverticulitis

The classic prior teaching for the treatment of diverticulitis includes:

Hospital admission
Bowel rest (NPO)
IV fluids
Broad spectrum IV antibiotics

Do ALL patients need to be admitted? There is some early literature suggesting that there is a small sub-population who fare well with outpatient treatment.

This article from Annals of EM in the “Best Available Evidence” series summarizes the existing literature well.

PV Card: Diverticulitis

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Word of caution

This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I’d still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.

Still it’s nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.

Reference

Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011;57(6):600-602. doi: 10.1016/j.annemergmed.2010.11.008

By Michelle Lin, MD|2021-10-13T08:49:38-07:00May 27, 2011|ALiEM Cards, Gastrointestinal|

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