“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?
Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.
Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?
Once you have significant soft tissue injury, you are automatically have a Type III fracture and should add an aminoglycoside.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground. She’s crying because of the event but is otherwise unscathed. At this point it’s time to take care of the avulsion. What to do?
Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique
Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.
In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.
Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.
There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?
In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.
Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Thanks to Dr. Michael McGonigal at Trauma Professional’s Blog for posting about this.
Serotonin syndrome is caused by the excess of serotonin and presents classically as:
Fortunately, there’s a nice algorithm (Hunter’s decision rule) which helps you decide whether it is serotonin syndrome or not. I also include a table, which I adapted from a New England Journal of Medicine review article, which helps you to differentiate it from its mimickers, such as anticholinergic syndrome, neuroleptic malignant syndrome, and malignant hyperthermia.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
A video to remind you what clonus looks like:
Thanks to Dr. Steve MacDade (Univ of Florida, Jacksonville EM resident) for the idea!
As a followup to the blog on the Captain Morgan technique for hip dislocations, I’d like to throw out another similar technique that also does NOT involve climbing up on the gurney.
Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient’s bed.
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