How do you capture the image of the eye on slit lamp exam either for the patient or your ophthalmology consult? It’s often easier to show someone a photo rather than trying to describe that atypical dendritic lesion, degree of corneal edema, or pattern of corneal abrasion.
You, however, don’t have the expensive camera attachment (nor a SLR camera for that matter).
Medication error is something that we all fear in Emergency Medicine and do our best to avoid. Here’s a scenario and simple approach for you, provided by Zlatan Coralic, PharmD (Assistant Clinical Professor in the UCSF School of Pharmacy).
You are an emergency physician working in an underserved country. You are presented with an asthmatic kid with severe retractions and tight wheezes. Multiple nebulizers and corticosteroids have failed. You want to try some magnesium sulfate before risking intubation in a place with no reliable access to ventilator equipment. You know the dose should be 1 gm IV over 20 minutes.
A patient presents with a tungsten ring on their injured finger and is unable to remove the ring. Tungsten rings are unique in that ring cutters can’t even make a scratch in them. There are even anecdotes of firefighter equipment not being able to cut off these “unbreakable” rings.
A patient’s PICC line becomes obstructed and presents to your ED for care. She is using it for chronic antibiotics for osteomyelitis. You are unable to aspirate and flush it with saline using a 10 cc syringe.
Do you always get a troponin for patients who sustain blunt chest trauma?
Hopefully your answer is no. Of note, it is also NOT indicated as a screening test for those in whom you suspect a blunt cardiac injury (BCI). It can be normal in the setting of arrhythmias and it can be falsely elevated in the setting of catecholamine release or reperfusion injury from hypovolemic shock.
The initial screening test should include an ECG and a FAST ultrasound exam. If you have abnormal ECG findings, then a troponin is warranted (in addition to hospital admission).
Below summarizes a suggested algorithm from the recent EM Clinics of North America publication series. Definitive statements are challenging because there is no gold standard to diagnose BCI.
Adapted from [1]
Go to the ALiEM (PV) Cards for more resources.
Last week, Dr. David Johnson shared his trick to elicit a Valsalva maneuver out of his patient. Here’s another trick that I saw one of our EM residents use in an attempt to break a SVT rhythm.
Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol, methanol), this Paucis Verbis card focuses on isopropyl alcohol toxicity, which is commonly found in rubbing alcohols. In this toxic alcohol, fomipezole is actually NOT indicated because you want to have alcohol dehydrogenase convert the toxic parent compound (isopropyl alcohol) into the nontoxic metabolite (acetone).
Note that these are merely guidelines and you should tailor management plans with your toxicologist and nephrologist.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
