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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: Composition of intravenous fluids

iv bagThere has been a lot of discussion on the ideal intravenous fluids (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs. This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what’s in 1 liter of normal saline. As it turns out, normal saline is not really “normal”. Dr. Scott Weingart has a great podcast on “chloride poisoning” using IVFs.

This PV card helps remind me what’s in each liter bag of fluids we order (composition of intravenous fluids). At the bottom half of the card is a brief summary of the JAMA findings.

PV Card: IV Fluid Formations


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

Update 1/4/13

After the posting of this PV card, there was intense discussion about why the D5W osmolarity was 252 mOsm/L instead of 272 mOsm/L, which is found on various medical calculators. See the discussion by Dr. Joel Topf.

Has this JAMA study changed your approach to ED intravenous fluid management?

It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.

Reference

  1. Yunos N, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572. [PubMed]
By |2021-10-08T09:49:07-07:00Jan 3, 2013|ALiEM Cards, Tox & Medications|
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PV card: Metacarpal fractures

metacarpal fracture rotationa angulationa=Patients with rotation deformities of the fingers from a metacarpal fracture should be reduced. All fingers should normally point towards the patient’s scaphoid bone.

Metacarpal (MC) fractures are common injuries, which often spark discussions about whether they should be reduced in the ED urgently.

  • What are the criteria for acceptable degrees of angulation? Are these criteria different for the MC neck versus shaft?
  • Which fractures tend to be unstable and thus require eventual operative repair?
  • How should I splint the injury?

Here’s a quick-reference card to help guide your management decisions. These recommendations may vary slightly based on what references you use. You may need to tailor your decisions based on your regional practices.

PV Card: Metacarpal Fractures


Go to ALiEM (PV) Cards for more resources.

 

Thanks to Dr. Nicole Strauss at the UCSF-SFGH Orthopaedic Trauma Institute and my go-to hand expert for her input.

By |2021-10-08T09:33:03-07:00Dec 13, 2012|ALiEM Cards, Orthopedic|
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PV card: PE Severity Index (PESI) score

pulmonary embolism PE PESI score

Do you send some of your low-risk patients with pulmonary embolism home?

This is a controversial issue which warrants a look at risk stratification tools. The primary one used is the validated Pulmonary Embolism Severity Index (PESI) score. In Lancet 2011, the authors looked at whether PESI class I and II (low risk) patients could be managed safely as outpatients. It turns out in their study, regardless of whether their PESI class I and II patients were treated as outpatients and inpatients, all fared equally well from a complications standpoint (recurrent clot, bleeding from anticoagulation).

I like the validated PESI scoring system to risk-stratify patients as low vs high risk for complications. I, however, do caution people to look closely at the exclusion criteria for this study before applying this to all ED patients.

The exclusion filter was so strict that they likely have captured a very narrow and unrealistic scope of patients to be widely applicable. It makes sense from a research standpoint to have these criteria to achieve internal validity but the question is external validity. Two exclusion criteria that struck me as awfully strict were: (1) needing parenteral opioids or (2) active alcohol or drug abuse.

Bottom line

For me, this study alone seems not have enough external validity to decide about the decision to treat PE patients as inpatient vs outpatient. Although I think that ultimately some can be managed as outpatients, I’d like to see more studies.

PV Card: PESI Score for Pulmonary Embolism


See other ALiEM (PV) Cards.

By |2021-10-08T09:35:48-07:00Nov 17, 2012|ALiEM Cards, Cardiovascular, Pulmonary|
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PV Card: Electrolytes and ECG changes

ECG anatomy segments

The electrocardiogram can pick up all sorts of electrolyte abnormalities. The most common abnormalities revolve around high and low levels of potassium and calcium. Magnesium derangements typically have nonspecific findings. How do you keep things straight? To make things more complicated, multiple electrolyte derangements can occur at the same time, making ECG interpretation challenging.

(more…)

By |2021-10-08T09:38:57-07:00Sep 21, 2012|ALiEM Cards, ECG, Endocrine-Metabolic|
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Paucis Verbis: EMTALA rules in the transfer of ED patients

NoDumping

In U.S. academic emergency departments, decisions to accept patients is typically easy, because you have ready access to on-call physicians. When in doubt, accept transfer patients and sort things out later.

  • What are the obligations for those transferring patients to other EDs?
  • What do the EMTALA (a.k.a. “anti-dumping”) rules say?
  • When can you transfer unstable patients?

As a general rule, the liability falls upon the transferring site and physician. So be sure that your patient won’t decompensate in the ambulance during transfer. So, don’t transfer that CP patient who is getting ruled-out for an MI or ACS no matter how good they look. Patients need to be stable for transfer.

Anyone with pearls to share?
Thanks to @EMurgentologist for tweeting me the idea!

PV Card: EMTALA Transfer Rules


Go to ALiEM (PV) Cards for more resources.

Further Reading:

By |2026-06-16T16:02:29-07:00Sep 14, 2012|Administrative, ALiEM Cards|
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Paucis Verbis: Delayed sequence intubation

Bipap

A 40-year-old man presents with significant agitation and severe respiratory distress from a COPD exacerbation. His oxygen saturation is 75% on room air, and he has diffuse, tight wheezes on exam. You prepare to intubate the patient using a rapid sequence induction protocol: etomidate, succinylcholine, 8-0 endotracheal tube.

Or do you?

This pocket card discusses the delayed sequence intubation (DSI) protocol made famous by Dr. Scott Weingart and Dr. Rich Levitan.1 Thanks to Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob (Intermountain Medical Center in Utah) for designing this helpful card. Rob has even implemented a DSI protocol in his ED.

The card breaks down the reasoning and steps behind DSI. Anecdotally, ketamine has often calmed patients down enough during the preoxygenation phase to enhance oxygenation/ventilation so much so that intubation is not required.

PV Card: Delayed Sequence Intubation (DSI)


Go to ALiEM (PV) Cards for more resources.

Reference

  1. Weingart S, Levitan R. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-75.e1. [PubMed]
By |2022-04-05T15:07:58-07:00Aug 31, 2012|ALiEM Cards, Critical Care/ Resus|
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