Sometimes classic techniques need to be revisited, especially when I get new photos from the collective readership. Let’s review a painless way to remove beads from the ear canal. You can’t exactly have the patient’s provider blow in the other ear to expulse the bead, similar to a nasal foreign body…
Do you know what the Blatchford clinical prediction score is for upper GI bleeding? It can help you predict whether a patient with an upper GI bleed is severe and requires urgent intervention.
Hot off the presses, JAMA just came out with a great Clinical Rational Examination article on this topic. Thanks to Dr. Ryan Radecki (EMLitOfNote) for the heads up. The likelihood ratios and Blatchford risk stratification score are so useful that I’m breaking my PV rule to keep things down to the size of one index card. Note the absence of a NG lavage result to help you risk stratify for an upper GI bleed requiring urgent intervention using the Blanchard score.
Let’s say you have a patient with a Blanchard score of 0, as in the case of the JAMA example. Starting with a general 30% pretest probability that your upper GI bleed patient has a severe GI bleed, your post-test probability becomes <1% for a severe GI bleed.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
Three weeks ago, I talked about more safely reducing mandibular dislocations. After successful completion of the procedure, how do you make sure that the patient doesn’t re-dislocate the mandible? You definitely should tell the patient to keep their jaw closed as much as possible for the next 24 hours and avoid opening the mouth widely (eg. yawning/laughing).
How do you immobilize the mandible? Especially for the chronic dislocators, presumably with more lax TMJ ligaments, you should think about immobilization. This can be done with a head bandage which goes under the chin. You can use kerlix rolls or an ACE wrap.
You identify a great external jugular (EJ) vein to cannulate for IV access. You are having a hard time keeping the angle of the angiocatheter aimed at a shallow angle because the mandible is in the way. This is typical of patients with chubby necks (eg. pediatric patients) or who are unable to rotate their neck.
A few months ago, American Family Physician published a nice review article on the diagnosis and management of genital ulcers. How do you remember the classic appearances of the lesions? I often quickly check references to confirm my suspicions.
I find the two following tables helpful to remember. The table of differential diagnoses is from AFP. The article also reviews the confirmatory diagnostic testing and treatment protocols. The table of the clinical characteristics for the main infectious causes is from “The Practitioner’s Handbook for the Management of Sexually Transmitted Disease”.
Note: Although the primary lesion from Lymphogranuloma venereum (LGV) can have a variable appearance the tender, and often suppurative lymphadenopathy (buboes) are classic.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Most recent 2010 CDC treatment guidelines
A 40 year-old man presents with a traumatic hemopneumothorax. He weighs 400 pounds.
Chest tubes can sometimes be challenge, especially for those with extra redundant tissue to tunnel through before reaching the intrathoracic cavity. You want to avoid placing the chest tube mistakenly in the subcutaneous space. How can you ensure that your chest tube actually reaches the intrathoracic space?
Does anyone think that this is generally a bad idea when closed-reducing mandible dislocations? Yes, it’s easiest to apply downward pressure on the mandible by pushing down on the occlusal surfaces of the molar teeth. Sometimes, however, when the mandible relocates into place, the teeth clamp shut abruptly – placing your thumbs at risk. How can you prevent any injuries to yourself?
One way is to slide gauze into the mouth during your procedure. Start the video around the 1:30 mark for an exam.
Apply a protective roll of gauze over each thumb. Additionally, you can wear a second glove to cover the gauze. No, those are NOT just fat thumbs under the gloves.
Thanks to Dr. Liz Brown (UCSF-SFGH EM resident) for the trick!