One of the indications for nasogastric (NG) tube placement is to instill fluids or medications. This may be saline or water for NG lavages or charcoal. You can manually push fluids into the NG tube via a 60 cc syringe, but this may take a long time for large volumes.
One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?
Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.
One of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There’s never before been a published diagnostic guideline or algorithm which helps you with risk-stratification.
In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less helpful.
Unfortunately, they didn’t study the utilization rate of the MRI scanner with this guideline. Are they getting better results (fewer diagnostic delays and fewer cases of patients later in their clinical course) because they are just MRI-scanning more people? Almost everyone in my ED with back pain would fall into the Urgent/Emergent MRI box… I’m not a fan of this algorithm.
Regardless, this algorithm may help you in shaping your diagnostic decision and medical decision making documentation.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Back in July 2010, I wrote about using the Candleflame app to encourage pediatric patients to take deep breaths for a pulmonary exam. This app has also been useful in helping me roughly gauge the patient’s peak flow.
This Paucis Verbis card summarizes recommendations found in Circulation’s recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Scalp lacerations are a common condition in the Emergency Department. Some require no bandage over once the injury is repaired. Because the scalp is so vascular, others require a pressure dressing over the site to minimize hematoma formation.
How do you bandage these patients? It is difficult to secure any wrap or square gauze over the site, because the head is round and the hair is slippery.
In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.
My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.