Trick of the Trade: Laryngospasm notch maneuver

What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED?

Answer = 0.3%

A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it.

You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?

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By Michelle Lin, MD|2016-11-11T19:00:18-08:00Dec 1, 2010|Pediatrics, Tricks of the Trade|

Trick of the Trade: Hemostasis of bleeding finger laceration using a glove

Lacerations of the finger can bleed quite profusely because of digital vascularity. This obscures the provider’s ability to perform a careful exam and can make suturing quite difficult. Simple direct pressure over the laceration often controls the bleeding.

What if this doesn’t work?

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By Michelle Lin, MD|2019-06-13T09:47:17-07:00Nov 24, 2010|Tricks of the Trade|

Paucis Verbis: Identifying toxidromes by vital signs

A middle-age woman presents to the Emergency Department with altered mental status after having ingested a drug. Is it an opioid? Is it an antihistamine?

The key is to pay close attention to the vital signs. They are often the clue to the mystery. I found this great table from EM Clinics of North America by Dr. Timothy Erickson from 2007. I can’t imagine how long it took for him to create all these mnemonics. I’ll never remember these mnemonics, but they’re fun to read nonetheless.

PV Card: Toxidromes by Vital Signs

Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-17T09:22:42-07:00Nov 19, 2010|ALiEM Cards, Tox & Medications|

New 2010 ACLS guidelines from the AHA, ERC, and ILCOR

Last month the AHA, ERC, and ILCOR released the 2010 Resuscitation Guidelines. They build on the 2005 and previous guidelines and continue the trend towards more, higher quality, uninterrupted CPR. The complete summary and recommendations are published in Circulation and are available for free.

Here is my summary for you!

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By Demian Szyld, MD EdM|2019-09-05T20:31:26-07:00Nov 18, 2010|Cardiovascular, Guideline Review|

Trick of the Trade: Toe paronychia splinting

Ingrown toenails, or paronychias, are usually exquisitely painful and a bit gnarly when they present to you in the Emergency Department. Dr. Stella Yiu described toenail splinting techniques using steristrips or dental floss. The purpose of splinting is to prevent the toenail from growing back into the lateral nail fold.

This assumes a relatively mild-to-moderate case. Often simple elevation of the nail out of the lateral nail fold (under digital block anesthesia) is all that is needed to treat a paronychia. Pus is often released with this maneuver.

What do you do for more severe cases when you have to excise the lateral edge of the nail?

There’s no toenail to slide the steristrip/ cotton/ dental floss material under.

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By Michelle Lin, MD|2019-01-28T23:16:45-08:00Nov 17, 2010|Tricks of the Trade|

Trick of the Trade: Ultrasound-guided supraclavicular central line

Emergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots

Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer.

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By Michelle Lin, MD|2016-11-11T19:00:20-08:00Nov 10, 2010|Tricks of the Trade, Ultrasound|

Paucis Verbis: Sgarbossa’s Criteria with LBBB

It is difficult to determine if a patient with a left bundle branch block (LBBB) has an acute myocardial infarction (AMI) because ST segments are “appropriately discordant” with the terminal portion of the QRS. That means if the QRS complex is negative (or downgoing), the ST segment normally will be positive (or elevated). Similarly if the QRS complex is positive (or upgoing), the ST segment will be negative (or depressed).

PV Card: Sgarbossa’s Criteria

In 1996, Sgarbossa et al looked through the GUSTO-1 trial patients with LBBB and AMI. They derived 3 criteria which may help diagnose the “hidden” AMI. The criteria are:

1. ST elevation ≥ 1 mm concordant with QRS complex (most predictive of AMI of the 3 criteria)
2. ST depression ≥ 1 mm in lead V1, V2, or V3
3. ST elevation ≥ 5 mm where discordant with QRS complex

Use these criteria with caution though. None of these criteria are perfect. They are to help you risk-stratify. For instance, criteria #3 (ST elevation ≥ 5 mm) can exist in asymptomatic patients with LBBB because of concurrent left ventricular hypertrophy and high voltages.

Thanks to Tom Bouthillet at ems12lead.com for the useful illustration above.

Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-17T09:25:38-07:00Nov 5, 2010|ALiEM Cards, Cardiovascular, ECG|