Paucis Verbis: D-Dimer test

D-Dimer: To order or not to order?

That’s the question when it comes to risk stratifying a patient for a pulmonary embolism with a low pretest probability. One should consider confounding conditions which may cause an elevated D-Dimer level. There’s always confusion about what may cause an elevated D-Dimer besides venous thromboemboli. So I thought I would make a pocket card as a reminder.

PV Card: D-Dimer Test

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

Reference

Wakai A, Gleeson A, Winter D. Role of fibrin D-dimer testing in emergency medicine. Emerg Med J. 2003;20(4):319-325. [PubMed]

By Michelle Lin, MD|2021-10-10T08:49:42-07:00Jul 27, 2012|ALiEM Cards, Cardiovascular, Pulmonary|

Trick of the Trade: Photograph slit lamp findings

How do you capture the image of the eye on slit lamp exam either for the patient or your ophthalmology consult? It’s often easier to show someone a photo rather than trying to describe that atypical dendritic lesion, degree of corneal edema, or pattern of corneal abrasion.

You, however, don’t have the expensive camera attachment (nor a SLR camera for that matter).

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By Michelle Lin, MD|2019-01-28T22:18:01-08:00Jul 24, 2012|Ophthalmology, Tricks of the Trade|

Trick of the Trade: Converting % to mg/mL

Medication error is something that we all fear in Emergency Medicine and do our best to avoid. Here’s a scenario and simple approach for you, provided by Zlatan Coralic, PharmD (Assistant Clinical Professor in the UCSF School of Pharmacy).

You are an emergency physician working in an underserved country. You are presented with an asthmatic kid with severe retractions and tight wheezes. Multiple nebulizers and corticosteroids have failed. You want to try some magnesium sulfate before risking intubation in a place with no reliable access to ventilator equipment. You know the dose should be 1 gm IV over 20 minutes.

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By Zlatan Coralic, PharmD|2016-11-11T18:44:27-08:00Jul 17, 2012|Tox & Medications, Tricks of the Trade|

Paucis Verbis: Blunt cardiac injury

Do you always get a troponin for patients who sustain blunt chest trauma?

Hopefully your answer is no. Of note, it is also NOT indicated as a screening test for those in whom you suspect a blunt cardiac injury (BCI). It can be normal in the setting of arrhythmias and it can be falsely elevated in the setting of catecholamine release or reperfusion injury from hypovolemic shock.

The initial screening test should include an ECG and a FAST ultrasound exam. If you have abnormal ECG findings, then a troponin is warranted (in addition to hospital admission).

Below summarizes a suggested algorithm from the recent EM Clinics of North America publication series. Definitive statements are challenging because there is no gold standard to diagnose BCI.

PV Card: Blunt Cardiac Injury

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

Reference

Bernardin B, Troquet J. Initial management and resuscitation of severe chest trauma. Emerg Med Clin North Am. 2012;30(2):377-400, viii-ix. [PubMed]

By Michelle Lin, MD|2021-10-10T08:52:32-07:00Jun 29, 2012|ALiEM Cards, Cardiovascular, Trauma|

Paucis Verbis: Toxic alcohols – Isopropyl alcohol

Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol, methanol), this Paucis Verbis card focuses on isopropyl alcohol toxicity, which is commonly found in rubbing alcohols. In this toxic alcohol, fomipezole is actually NOT indicated because you want to have alcohol dehydrogenase convert the toxic parent compound (isopropyl alcohol) into the nontoxic metabolite (acetone).

Note that these are merely guidelines and you should tailor management plans with your toxicologist and nephrologist.

PV Card: Isopropyl Alcohol Toxicity

Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.

References

Kraut J, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol. 2008;3(1):208-225. [PubMed]
Jammalamadaka D, Raissi S. Ethylene glycol, methanol and isopropyl alcohol intoxication. Am J Med Sci. 2010;339(3):276-281. [PubMed]

By Michelle Lin, MD|2021-10-10T08:56:50-07:00Jun 22, 2012|ALiEM Cards, Tox & Medications|

Paucis Verbis: Toxic alcohols – Methanol

Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol), this Paucis Verbis card focuses on methanol toxicity. Useful are the American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis. I redrew the flowchart based on what’s relevant to the ED in the initial stages.

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By Michelle Lin, MD|2021-10-19T19:44:59-07:00Jun 15, 2012|ALiEM Cards, Tox & Medications|

Paucis Verbis: Toxic alcohols – Ethylene glycol

Following last week’s Paucis Verbis card on calculating the osmolal gap, here is the first installment of the Toxic Alcohols cards. First up — ethylene glycol. There are useful American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis.

Here’s a quick review of the metabolism of the different toxic alcohols. The parent compounds for ethylene glycol and methanol are innocuous and the metabolites are toxic.

PV Card: Ethylene Glycol Toxicity

Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.

See Dr. Leon Gussow’s great review on The Poison Review and tips of a recent Annals of EM4 paper on identifying a small subset of patients with ethylene glycol who did well despite NOT receiving hemodialysis.

References

Kraut J, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol. 2008;3(1):208-225. [PubMed]
Jammalamadaka D, Raissi S. Ethylene glycol, methanol and isopropyl alcohol intoxication. Am J Med Sci. 2010;339(3):276-281. [PubMed]
Marraffa J, Cohen V, Howland M. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm. 2012;69(3):199-212. [PubMed]
Levine M, Curry S, Ruha A, et al. Ethylene glycol elimination kinetics and outcomes in patients managed without hemodialysis. Ann Emerg Med. 2012;59(6):527-531. [PubMed]

By Michelle Lin, MD|2026-06-16T16:02:38-07:00Jun 8, 2012|ALiEM Cards, Tox & Medications|