Trick of the Trade: My new penlight

On any given day in the ED, I use my super-bright penlight 2-5 times a day. It is amazing what things I’ve almost missed without a bright LED flashlight.

Subtle HSV-2 labial ulcerations in a female patient with dysuria
Additional scalp lacerations hidden in the hair
Tonsillar exudates in a patient with strep pharyngitis
Unequal pupillary responses in a brightly lit trauma room in a head-injured patient

I wanted to revisit a prior post about the importance of changing your Tungsten penlight to a LED light.

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By Michelle Lin, MD|2019-01-28T23:47:58-08:00Feb 17, 2010|Tricks of the Trade|

Paucis Verbis card: Urinary tract infection

In this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Urinary Tract Infection. UTIs are one of the most common infections that we treat in the Emergency Department.

PV Card: Urinary Tract Infection

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

Reference

Norris D, Young J. Urinary tract infections: diagnosis and management in the emergency department. Emerg Med Clin North Am. 2008;26(2):413-30, ix. [PubMed]

By Michelle Lin, MD|2021-10-19T19:10:04-07:00Feb 12, 2010|ALiEM Cards, Genitourinary|

Beware the hidden tibia plateau fracture

Find the fracture in this patient with blunt knee trauma.

As a general rule, plain films are insensitive in ruling out orthopedic injuries. One particularly tricky area is the knee. This 2-view knee series above is normal.

Did you know that the sensitivity of picking up knee fractures is as low as 79% with a 2-view series and 85% with a 4-view series? With the advent of CT imaging, more and more subtle fractures are being found.

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By Michelle Lin, MD|2016-11-11T19:01:36-08:00Feb 11, 2010|Orthopedic, Radiology|

Trick of the trade: Minimizing post-LP headache

Have you ever performed a lumbar puncture (LP) in a patient, only to have them return the next day for new debilitating headaches? It’s worse when sitting up, and much improved when laying down. You hate adding more problems for the patient, put you are certain that s/he now has a post-LP headache.

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By Michelle Lin, MD|2016-11-11T19:01:37-08:00Feb 10, 2010|Tricks of the Trade|

Paucis Verbis card: Pediatric blunt head injury

In this installment of the Paucis Verbis (In a Few Words) e-card series, the topic is Pediatric Blunt Head Trauma.

This a particularly relevant topic given the recent press and discussions about CT irradiation and the cancer risk especially in pediatric patients. It’s also relevant since Dr. Nate Kuppermann (UC Davis) just gave Grand Rounds at our UCSF-SFGH EM residency program. He first-authored a landmark 2009 Lancet article on minor head injury in kids.

PV Card: Pediatric Blunt Head Trauma

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

Update June 27, 2017

We collaborated with PECARN and CanadiEM to create visual PECARN’s official decision tool.

Reference

Kuppermann N, Holmes J, Dayan P, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. [PubMed]

By Michelle Lin, MD|2021-10-19T19:12:36-07:00Feb 5, 2010|ALiEM Cards, Pediatrics, Trauma|

Trick of the Trade: Preventing tissue adhesive seepage

As great as tissue adhesives are in wound closure, they come with some risk. For instance, liquid adhesives, such as Dermabond, can “run” and contact undesired areas such as eyelid margins. Careful application of tissue adhesives is critical.

How can you minimize the amount of seepage of tissue adhesive to undesired areas?

Trick of the Trade

Create an impermeable tape barrier

I already mentioned this in an earlier post in July, but I now have more experience with this technique. Here are some recent photos of this trick in action.

Cut out a circle from a transparent tape adhesive. In this case, I used a transparent Tegaderm which can be found with peripheral or central line IV kits.
Adhere the tape to the patient’s skin primarily along the circular edge to prevent glue seepage under the tape. You don’t need to stick the ENTIRE transparent tape to the patient, unless you want to pull off some eyebrow and eyelid lashes!
Apply the tissue adhesive glue over the wound while ensuring that the wound edges are closely approximated. Excess glue will run off onto the tape. You only need to wait a few seconds after glue application before peeling the tape off.

This idea was contributed by Dr. Hagop Afarian (UCSF-Fresno).

Thanks also to my Visual Aid Project photographer, Lourdes Adame, who photographed and consented the patient’s father for these photos. Her speaking fluent Spanish made them feel at ease and understand that we were photographing for educational purposes.

By Michelle Lin, MD|2019-02-04T03:35:20-08:00Feb 3, 2010|Tricks of the Trade|

Article review: Long axis view for IJ line placement

As bedside ultrasonography is becoming a staple in central line placement (especially of internal jugular lines), emergency physicians now can minimize complications, such as carotid artery puncture and a pneumothorax. Traditionally, the US probe is positioned along the short-axis of the IJ during the procedure (see right).

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By Michelle Lin, MD|2016-11-11T19:01:39-08:00Feb 1, 2010|Ultrasound|