Trick of the Trade: Fluorescein eyedrops

This is a guest post by Dr. Ian Brown (Stanford):

The Roberts textbook describes the procedure of corneal fluorescein staining as touching a moistened fluorescein strip to the cornea. Maybe it is an irrational fear of a paper cut to the sclera, or a fear of touching an already abraded cornea with the paper, but I try to find an alternative. I have seen physicians hold the eye open with one hand, hold the fluorescein with a second hand and then drip tetracaine on the paper and let it drip into the eye with a third hand. I, unfortunately, only have two hands.
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By Michelle Lin, MD|2019-01-28T23:36:28-08:00Mar 27, 2012|Ophthalmology, Tricks of the Trade|

Modern EM: Case 1 and 2 – Strep Throat

A sister and brother, aged 7 and 14, respectively present with pharyngitis. The 7F has sore throat, cough, fever, and post-tussive vomiting for 1 day. She has posterior pharyngeal erythema, no lymphadenopathy, no exudate, no petechiae, and looks like a viral URI.

The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved. Now, he’s in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, LAD, and petechiae on his hard palate.

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By Timothy Peck, MD|2017-03-05T14:18:48-08:00Mar 26, 2012|ENT, Social Media & Tech|

Paucis Verbis: Kawasaki Disease

Kawasaki Disease can be easy to diagnose when you have the pediatric patient, who presents with all 5 of the classic clinical findings. What happens when you have the prerequisite fever for ≥5 days, but only 2-3 clinical criteria?

What ARE the 5 classic findings?
When do you do waitful watching?
When do you perform an echo?
When do you treat empirically?

Check out the nice flowchart below which addresses these questions. They summarize the most recent (2004) American Heart Association’s consensus group’s recommendations.

PV Card: Kawasaki Disease (AHA 2004)

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

Reference

Newburger J, Takahashi M, Gerber M, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004;110(17):2747-2771. [PubMed]

By Michelle Lin, MD|2021-10-10T19:08:53-07:00Mar 23, 2012|ALiEM Cards, Cardiovascular, Pediatrics|

Trick of the Trade: Pelvic speculum for peritonsillar abscess

Peritonsillar abscess drainage in the ED continues to be one of my favorite procedures to perform. There are several tricks to increase your chances for a successful aspiration. One trick involves using a curved laryngoscope to help depress the tongue AND provide a bright light source.

What if you don’t have a laryngoscope readily available?

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By Michelle Lin, MD|2019-01-28T23:36:17-08:00Mar 20, 2012|ENT, Tricks of the Trade|

Paucis Verbis: Continuous Infusions

I have always been envious of the residents who carry around the Continuous Infusions cheat-sheet card, which was created by the UCSF Critical Care Units as part of a campaign for Safe Medication Prescriptions. I want one! So I finally managed to wrangle one away for a few minutes and xerox copy it. Here is the abbreviated card, after paring down the list to just ED-focused medications.

PV Card: Continuous Infusions

Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-10T19:14:04-07:00Mar 9, 2012|ALiEM Cards, Tox & Medications|

Paucis Verbis: Anaphylaxis

Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical.

A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of “rebound” or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn’t a good answer for this.

What’s your practice in dispositioning these patients? Personally, I admit at least those patients who present with severe hypotension, require more than 1 epinephrine dose, or have poor social support.

NOTE: Unlike the photo on the top, warn patients NOT to rest their thumb on the device because of the risk inadvertent needle puncture.

PV Card: Anaphylaxis

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

References

Arnold J, Williams P. Anaphylaxis: recognition and management. Am Fam Physician. 2011;84(10):1111-1118. [PubMed]
Simons FER. Anaphylaxis. Journal of Allergy and Clinical Immunology. 2010;125(2):S161-S181. doi: 10.1016/j.jaci.2009.12.981

By Michelle Lin, MD|2021-10-10T19:17:26-07:00Feb 24, 2012|ALiEM Cards, Allergy-Immunology|

Trick of the Trade: Minimizing propofol injection pain

“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz…

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection?

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By Michelle Lin, MD|2019-01-28T22:23:58-08:00Jan 24, 2012|Tox & Medications, Tricks of the Trade|