Trick of the Trade: Ultrasound-guided injection for shoulder dislocation

Who loves relocating shoulder dislocations as much as I do? I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?

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By Michelle Lin, MD|2019-01-28T22:35:26-08:00Nov 8, 2011|Orthopedic, Tricks of the Trade, Ultrasound|

Paucis Verbis: Acetaminophen toxicity

Did you know that the American Association of Poison Control Centers reports that 10% of poison center calls are related to acetaminophen ingestions? That’s a lot. This Paucis Verbis card reviews the basics of acetaminophen toxicity. I included the Rumack Matthew nomogram to help you plot out the patient’s risk for hepatotoxicity.

In the Emergency Department, we often screen for acetaminophen toxicity for patients who may have ingested substances as a suicide attempt. We check the serum acetaminophen level 4 hours post-ingestion. Occasionally, we are surprised by a toxic level because in the first 24 hours, because symptoms are can be mild and nonspecific (abdominal pain, nausea, lethargy).

Rule of 150

The toxic ingestion dose of acetaminophen is 150 mg/kg.
The serum acetaminophen level when N-acetylcysteine treatment should be started is 150 mcg/mL (see Rumack Matthew nomogram)
The starting IV dose of N-acetylcysteine is 150 mg/kg over 15 minutes.

PV Card: Acetaminophen Toxicity

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

Reference

Larson A. Acetaminophen hepatotoxicity. Clin Liver Dis. 2007;11(3):525-48, vi. [PubMed]

By Michelle Lin, MD|2021-10-11T15:53:18-07:00Nov 4, 2011|ALiEM Cards, Tox & Medications|

Trick of the trade: Nebulized naloxone

Overdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.

On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren’t near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don’t want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.

Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.

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By Michelle Lin, MD|2026-02-02T20:32:13-08:00Nov 1, 2011|Tox & Medications, Tricks of the Trade|

Paucis Verbis: Influenza – To treat or not to treat?

Influenza season typically peaks in the United States during the Jan-Feb months and can start as early as October. You can read about the 2011-12 seasonal flu data on the CDC website.

Should you give a patient with influenza an antiviral agent or just provide supportive therapy?

This Paucis Verbis card summaries the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations for this upcoming 2011-12 flu season. I also let patients with uncomplicated influenza who are going to be managed as outpatients know that a 5-day course of osteltamivir or zanamivir will cost them about $50-80. Often that sways them towards declining a prescription and “toughing out” an extra day of the flu.

PV Card: Influenza

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

Reference

Centers for. Infectious disease. Antiviral agents for the treatment and chemoprophylaxis of influenza. Ann Emerg Med. 2011;58(3):299-303; discussion 303-4. [PubMed]

By Michelle Lin, MD|2021-10-12T15:44:24-07:00Oct 28, 2011|ALiEM Cards, Infectious Disease|

Paucis Verbis: Ventilator settings for obstructive lung disease

Following up with last week’s Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation.

What initial ventilator settings should you set for these patients?

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.

By Michelle Lin, MD|2021-10-12T15:47:16-07:00Oct 21, 2011|ALiEM Cards, Pulmonary|

Paucis Verbis: Ventilator settings for acute lung injury and ARDS

A patient presents with severe multilobar pneumonia and refractory hypoxia requiring endotracheal intubation. The respiratory therapist connects your patient to the ventilator.

“What settings would you like your patient on?”

Back in 2010, Dr. Scott Weingart posted a great podcast on “Dominating the Vent“. It’s such a fantastic distillation of the practical aspect of ventilator setting management of all intubated patients except those with an acute asthma or COPD exacerbation, Dr. Jenny Wilson and I thought this would be a great Paucis Verbis card to have in your peripheral brain.

Note: The tidal volume should be calculated based on Predicted Body Weight (PBW), which is based on patient gender and height. The calculation is at the bottom of the card. Using a patient’s actual weight might yield a tidal volume that is way too high. The initial vent settings in the example box are for a patient with a PBW of 70 kg. That’s basically a 5’9″ man or 5’11” woman.

PV Card: Ventilator Settings for Lung Protection

Adapted from [1]
See ALiEM (PV) cards.

Thanks to Dr. Jenny Wilson for the idea and writing this card, and Dr. Scott Weingart for a great podcast as always.

Reference

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308. [PubMed]

By Michelle Lin, MD|2021-10-12T15:50:38-07:00Oct 14, 2011|ALiEM Cards, Pulmonary|

Trick of the trade: Quieting the shaky EKG tracing

A patient with Parkinson’s disease presents with chest pain to your ED. Her tremors prevent you from getting a good quality EKG because of the movement artifact.

How can you eliminate this artifact? (No cheating with rocuronium.)

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By Michelle Lin, MD|2019-01-28T22:36:03-08:00Oct 11, 2011|ECG, Tricks of the Trade|