It is 4 a.m. You pick up a chart. Toe pain.
Thinking this could be an easy injury, you walk over to the patient, only to discover: bilateral ingrown toenails. Your heart sinks. In your head, you are thinking: Lateral nail resection? Nail removal? This could take a while.
Is there a less invasive method for treating an ingrown toenail?
Have you been in a situation where you are the first to detect a cardiac murmur in a patient? If you are hearing it in a busy, loud Emergency Department, I find that it’s at least a grade III.
Should you order an echocardiogram for further outpatient evaluation? It depends on the grade and characteristic of the murmur, in addition to the patient’s symptoms. For instance, all diastolic murmurs require an echo. There is a useful ACC/AHA algorithm which helps you decide.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Thanks to Amy Kinard, an Emergency RN and aspiring Family Nurse Practitioner, for drafting this useful Paucis Verbis card for me during her studies. Keep the great ideas coming, everyone!
Bedside ultrasonography is increasingly being used in the ED to examine the eye. For instance, it can be used to detect a retinal detachment, vitreous hemorrhage, and high intracranial pressure. The technique involves applying ultrasound gel on the patient’s closed eyelid. A generous amount of gel should be used to minimize the amount of direct pressure applied on the patient’s eye by the ultrasound probe.
A patient presents to your Emergency Department with altered mental status and somnolence. You don’t smell alcohol on breath and you don’t see needle track marks. What clinical clue points you towards cocaine or methamphetamine ingestion?
Is your Emergency Department administering Tdap immunization boosters instead of dT boosters? Patients with wounds are getting updated not only for tetanus and diphtheria, but also now for pertussis.
Apparently there has been sharp rise in the national incidence of pertussis (Bordetella pertussis shown in image) in 2010. The infection has been documented in both infants (underimmunized less than 3 months old) and adolescents/adults (loss of immunity after 10 years). In fact, the CDC has issued an epidemic warning in California.
How do you diagnose pertussis ? What are the classic symptoms? Better yet, how do you rule-it out clinically?
You won’t like the answer. It often presents like the common cold and clinical symptoms are minimally helpful in making the diagnosis. So, according to the American Academy of Pediatrics, you should treat anyone under the age of 3 months in whom you suspect pertussis. Complications from pertussis in infants include apnea, seizures, secondary pneumonia, and death. That means any with an innocent cough should be treated with azithromycin!
The following is a meta-analysis article from JAMA on diagnosing pertussis in adolescents and adults.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.
How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.
Def Leppard may have been right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The prolapse often reduces spontaneously or with gentle manual pressure.
How do you risk-stratify undifferentiated chest pain patients in the Emergency Department? There are a multitude of causes for chest pain. We are always taught to think of the 5 big life-threats: ACS, PE, aortic dissection, tension pneumothorax, and pericardial tamponade.
So how do YOU risk-stratify your patients for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI)? STEMI’s are usually obvious. UA and NSTEMIs — not so much.
Fortunately a 2000 JAMA article and a followup Academic Emergency Medicine 2006 study have solidified the TIMI risk scoring system as a reasonable risk-stratification tool for all-comer ED patients with chest pain requiring an ECG.
Generally there is an upslope in risk at a TIMI score of 3 and greater.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
