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Trick of the Trade: Crossed straight leg raise test

SLRA 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica?

Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is the sciatic nerve.

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By |2016-11-11T18:52:17-08:00Aug 23, 2011|Orthopedic, Tricks of the Trade|
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Paucis Verbis: An approach to persistent tachycardia

Sinus Tachycardia ECG
Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can’t send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia?

Attached is a list of common causes of tachycardia in the ED, as well as potential diagnostic and therapeutic considerations. Rather than a shot-gun approach, a limited and thoughtful method works best.

Can you think of other potential causes?

PV Card: Approach to Persistent Tachycardia


Go to ALiEM (PV) Cards for more resources.

This useful PV card was made by one of our new star faculty members at San Francisco General Hospital, Dr. David Thompson. Thanks, David!

By |2021-10-12T16:15:00-07:00Aug 19, 2011|ALiEM Cards, Cardiovascular|
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Trick of the Trade: Splinting the ear

EarHematomaDressing

One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?

Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.

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By |2016-11-11T19:59:20-08:00Aug 10, 2011|ENT, Trauma, Tricks of the Trade|
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Paucis Verbis: Spinal epidural abscess

Spinal epidural abscess anatomy illustrationOne of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There’s never before been a published diagnostic guideline or algorithm which helps you with risk-stratification.

In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less helpful.

Not a practical algorithm

Unfortunately, they didn’t study the utilization rate of the MRI scanner with this guideline. Are they getting better results (fewer diagnostic delays and fewer cases of patients later in their clinical course) because they are just MRI-scanning more people? Almost everyone in my ED with back pain would fall into the Urgent/Emergent MRI box…  I’m not a fan of this algorithm.

Regardless, this algorithm may help you in shaping your diagnostic decision and medical decision making documentation.

PV Card: Spinal Epidural Abscess


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

Reference

  1. Davis D, Salazar A, Chan T, Vilke G. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14(6):765-770. [PubMed]
By |2021-10-12T16:17:13-07:00Aug 5, 2011|ALiEM Cards, Infectious Disease, Neurology|
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Paucis Verbis: Fibrinolytics for Acute Pulmonary Embolism

Pulmonary embolism fibrinolytics

When would you give fibrinolytics for a Pulmonary Embolism?

This Paucis Verbis card summarizes recommendations found in Circulation’s recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated.

PV Card: Fibrinolysis for Acute Pulmonary Embolism


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

Reference

  1. Jaff M, McMurtry M, Archer S, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788-1830. [PubMed]
By |2021-10-12T16:21:19-07:00Jul 29, 2011|ALiEM Cards, Cardiovascular, Pulmonary|
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Paucis Verbis: Diagnostic testing tips for acute abdominal pain

acute abdominal pain

In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.

My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation.


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

Reference

  1. Panebianco N, Jahnes K, Mills A. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin North Am. 2011;29(2):175-93, vii. [PubMed]
By |2021-10-12T16:23:35-07:00Jul 22, 2011|ALiEM Cards, Gastrointestinal, Radiology|
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Tricks of the Trade: Underwater ultrasonography

Basketweaving

I’ve heard of underwater basketweaving, but underwater ultrasonography?

Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient’s extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient’s skin and transducer. What’s a quicker and easier way to create some distance yet preserve image quality?

Trick of the Trade

Submerse both the body part and the ultrasound transducer under water.

ultrasonography water bath

For this “bath water technique”, start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.

FB_Hand

FB_Hand2

Thanks to Andy at Emergency Medicine Ireland blog for these 2 ultrasound images! 

This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient’s wound.

Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267

By |2020-04-21T12:30:07-07:00Jul 20, 2011|Tricks of the Trade, Ultrasound|
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