A health care worker hurried in to the ED after being poked with a needle.
‘It was an old 18G needle with dried blood’, she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, ‘What does very low risk mean?’
Is there another way to covery risk for patients?
With all of the amazing, sunny weather here in California, I feel (briefly) terrible for all those braving the snowpocalyptic conditions across the United States. So, in honor of all those bundled up and shivering, I wanted to review the management of accidental hypothermia.
Tip: Avoid jostling the hypothermic patient too much because of myocardial irritability. Don’t send your patient into an arrhythmia.
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Patients with a hairy chest may require little patches of hair to be shaved when applying EKG leads. This allows the leads to stick firmly to the chest. Loose leads will result in either an artifactual signal or no signal at all on the EKG machine.
How can you obtain an EKG without shaving little patches on the patient’s chest?
How many times have you had to look up the shoulder exam maneuvers for patients with acute shoulder pain? I don’t know why I just can’t seem to remember these.
This Paucis Verbis card is a quick reference card to remind you of the most common techniques. Thanks to Jenny for the idea.
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How do you manage patients who present in status epilepticus, knowing that “time is CNS function”? The longer patients remain seizing, the greater their morbidity and mortality.
Did you know that one study showed that 48% of their patients who presented in generalized convulsive status epilepticus (GCSE) had subtle persistent GCSE on EEG, despite no clinical evidence of overt seizure activity? That’s scary.
Do you send off a serum tricyclic toxicology screen for all your patients with GCSE? Because of the prevalence of TCA overdoses locally, our Neurology consultants definitely order it. We are picking up a surprising number of positive tricyclic tox screens.
Adapted from [1]
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We’ve all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? What if nothing happens?
Is there an alternative technique to reducing a nursemaid elbow?
How do you workup adult patients who present with a new-onset seizure and now neurologically back to normal?
There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches.
For the uncomplicated cases (age less than 40 years, afebrile, no comorbidities, no neurologic deficits), the workup is fairly minimal, which includes:
Otherwise, the more complex cases require a more extensive workup, which may include a lumbar puncture in the setting of a fever, severe headache, immunocompromised status, or persistent altered mental status.
Be sure you obtain a head CT for patients who you think are presenting with a simple new-onset, alcohol-withdrawal seizure. One study showed that 6.2% of these patients actually have a significant lesion on CT (eg. bleed, mass).
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.