Paucis Verbis: Methotrexate for ectopic pregnancy

Ectopic pregnancies account for as many as 18% of patients who present with first-trimester bleeding or abdominal pain in the Emergency Department. This Paucis Verbis card summarizes the 2008 American College of Obstetricians and Gynecologists (ACOG) guidelines on the use of methotrexate (MTX) for ectopic pregnancies. Not all ectopic pregnancies require operative management.

What are the indications and contraindications to MTX? When should they follow up with their obstetrician?

Answer: In 4 days for a repeat b-HCG and possible second dose of MTX

Note that one of the eligibility criteria is that the patient must have an “unruptured ectopic pregnancy”. Many would consider that any ultrasonographic evidence of free fluid may be a sign of an early rupture. It is left up to clinician judgment in how “unruptured” is interpreted.

PV Card: Methotrexate for Ectopic Pregnancy

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

Reference

ACOG Practice Bulletin No. 94: Medical Management of Ectopic Pregnancy. Obstetrics & Gynecology. 2008;111(6):1479-1485. doi: 10.1097/aog.0b013e31817d201e

By Michelle Lin, MD|2021-10-11T15:53:39-07:00Nov 11, 2011|ALiEM Cards, Ob/Gyn|

Trick of the Trade: Ultrasound-guided injection for shoulder dislocation

Who loves relocating shoulder dislocations as much as I do? I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?

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By Michelle Lin, MD|2019-01-28T22:35:26-08:00Nov 8, 2011|Orthopedic, Tricks of the Trade, Ultrasound|

Paucis Verbis: Acetaminophen toxicity

Did you know that the American Association of Poison Control Centers reports that 10% of poison center calls are related to acetaminophen ingestions? That’s a lot. This Paucis Verbis card reviews the basics of acetaminophen toxicity. I included the Rumack Matthew nomogram to help you plot out the patient’s risk for hepatotoxicity.

In the Emergency Department, we often screen for acetaminophen toxicity for patients who may have ingested substances as a suicide attempt. We check the serum acetaminophen level 4 hours post-ingestion. Occasionally, we are surprised by a toxic level because in the first 24 hours, because symptoms are can be mild and nonspecific (abdominal pain, nausea, lethargy).

Rule of 150

The toxic ingestion dose of acetaminophen is 150 mg/kg.
The serum acetaminophen level when N-acetylcysteine treatment should be started is 150 mcg/mL (see Rumack Matthew nomogram)
The starting IV dose of N-acetylcysteine is 150 mg/kg over 15 minutes.

PV Card: Acetaminophen Toxicity

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

Reference

Larson A. Acetaminophen hepatotoxicity. Clin Liver Dis. 2007;11(3):525-48, vi. [PubMed]

By Michelle Lin, MD|2021-10-11T15:53:18-07:00Nov 4, 2011|ALiEM Cards, Tox & Medications|

Trick of the trade: Nebulized naloxone

Overdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.

On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren’t near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don’t want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.

Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.

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By Michelle Lin, MD|2026-02-02T20:32:13-08:00Nov 1, 2011|Tox & Medications, Tricks of the Trade|

Paucis Verbis: Influenza – To treat or not to treat?

Influenza season typically peaks in the United States during the Jan-Feb months and can start as early as October. You can read about the 2011-12 seasonal flu data on the CDC website.

Should you give a patient with influenza an antiviral agent or just provide supportive therapy?

This Paucis Verbis card summaries the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations for this upcoming 2011-12 flu season. I also let patients with uncomplicated influenza who are going to be managed as outpatients know that a 5-day course of osteltamivir or zanamivir will cost them about $50-80. Often that sways them towards declining a prescription and “toughing out” an extra day of the flu.

PV Card: Influenza

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

Reference

Centers for. Infectious disease. Antiviral agents for the treatment and chemoprophylaxis of influenza. Ann Emerg Med. 2011;58(3):299-303; discussion 303-4. [PubMed]

By Michelle Lin, MD|2021-10-12T15:44:24-07:00Oct 28, 2011|ALiEM Cards, Infectious Disease|

Trick of the Trade: Nasal cannula oxygenation during endotracheal intubation

You are managing a 300-pound patient with a long history of severe COPD, who now requires intubation because of a pneumonia and COPD exacerbation. You anticipate that the patient may be a difficult airway intubation and may desaturate quickly during laryngoscopy. While you are setting up to orotracheally intubate this patient, you preoxygenate this patient as best as you can with a non-rebreather mask.

What can you do to prolong the patient’s time-to-desaturation so that you aren’t as rushed to place the endotracheal tube?

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By Michelle Lin, MD|2019-01-28T22:35:50-08:00Oct 25, 2011|Tricks of the Trade|

Paucis Verbis: Ventilator settings for obstructive lung disease

Following up with last week’s Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation.

What initial ventilator settings should you set for these patients?

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.

By Michelle Lin, MD|2021-10-12T15:47:16-07:00Oct 21, 2011|ALiEM Cards, Pulmonary|