Paucis Verbis: Post-exposure prophylaxis (non-occupational)

You know how chief complaints present to the ED in multiples? In one week, I had several cases where patients were asking for post-exposure prophylaxis treatment NOT in the content of a sexual assault. I haven’t had to manage such cases in a long time and so needed to look up the recent guidelines from the CDC.¹

The trick is not to forget about all the co-existing problems and infections beyond just HIV. Specifically, don’t forget about gonorrhea, chlamydia, and trichomonas.

PV Card: Post-Exposure Prophylaxis for Non-Occupational Contact

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

References

STD Treatment. Centers for Disease Control. http://www.cdc.gov/std/treatment/default.htm.
Landovitz RJ, Currier JS. Postexposure Prophylaxis for HIV Infection. New England Journal of Medicine. 2009;361(18):1768-1775. doi: 10.1056/nejmcp0904189

By Michelle Lin, MD|2021-10-15T11:21:12-07:00Apr 1, 2011|ALiEM Cards, Infectious Disease|

Trick of the Trade: Steristrip-suture combo for thin skin lacerations

Lacerations of elderly patients or chronic corticosteroid users can be a challenge because they often have very thin skin. Sutures can tear through the fragile skin. Tissue adhesives may not adequately close the typically irregularly-edged laceration.

How do you repair these lacerations?
Do you just slap a band-aid on it?

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By Michelle Lin, MD|2019-11-29T18:57:44-08:00Mar 30, 2011|Geriatrics, Trauma, Tricks of the Trade|

Paucis Verbis: Chemical sedation for severe agitation

Haldol, Ativan, and Versed… oh my.

In the Emergency Department, some patients present very acutely and aggressively agitated. This is usually the result of illicit drug use or a schizophrenic who hasn’t been taking medications (or both!). Fortunately, we have an arsenal of medications to help sedate the patient.

One study looked to answer the question of what single IM sedation agent is most effective, as measured by the shortest time to sedation and time to arousal.

PV Card: Chemical Sedation for Agitation

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

Reference

Nobay F, Simon BC, Levitt MA, Dresden GM. A Prospective, Double-blind, Randomized Trial of Midazolam versus Haloperidol versus Lorazepam in the Chemical Restraint of Violent and Severely Agitated Patients. Academic Emergency Medicine. 2004;11(7):744-749. doi: 10.1197/j.aem.2003.06.015

By Michelle Lin, MD|2021-10-16T19:23:38-07:00Mar 25, 2011|ALiEM Cards, Tox & Medications|

Trick of the Trade: Benzoin for opening traumatic, swollen eyelids

Patients who sustain facial trauma often have swollen eyelids. They may be so swollen that it is impossible to pull back the eyelids for an ocular exam. You use one of our “Tricks of the Trade”ideas and attempt to “roll” the upper eyelid using the Q-tip trick (above).

Fresh blood on the face, however, makes the Q-tip a little slippery along the upper eyelid, preventing an adequate view of the eye itself.

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By Michelle Lin, MD|2016-11-25T15:43:21-08:00Mar 23, 2011|Ophthalmology, Tricks of the Trade|

Paucis Verbis: Strength of diagnostic tests for cholecystitis

You have a 40 year-old man who presents to the ED for persistent right upper quadrant abdominal pain for 12 hours after eating a fatty meal. He has no fevers, nausea, flank pain, or dysuria. His physical exam shows no fever and only moderate tenderness in the RUQ without guarding. He has a Murphy’s sign which is improved after a total of 8 mg of IV morphine. His laboratory results, which include a WBC, liver function tests, lipase, and urinalysis, are normal.

Can you safely say that the patient doesn’t have cholecystitis? Can you discharge him for outpatient ultrasonography to assess for symptomatic cholelithiasis?

As bedside ultrasonography becomes more of a staple in Emergency Departments, it is easy to just perform the ultrasound yourself if such a patient presents. If you do not have an ED ultrasound available, however, you need to send this patient for a formal ultrasound because he is still very much at risk for cholecystitis despite having unremarkable lab tests and no fever.

JAMA published a meta-analysis of 17 studies on the test characteristics for cholecystitis. I found it odd that they defined a fever as temperature >35 Celsius. The best performing characteristic was a Murphy’s sign, although the positive likelihood ratio (LR) slightly crossed 1.0 (0.8-8.6).

PV Card: Diagnostic Testing for Cholecystitis

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

Reference

Trowbridge RL, Rutkowski NK, Shojania KG. Does This Patient Have Acute Cholecystitis? JAMA. 2003;289(1). doi: 10.1001/jama.289.1.80

By Michelle Lin, MD|2021-10-16T19:25:53-07:00Mar 18, 2011|ALiEM Cards, Gastrointestinal|

Trick of the Trade: Topical anesthetic cream for cutaneous abscess drainage in children

Abscess drainage can be painful and time consuming in the ED. Can this article help? ¹

Trick of the Trade

Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D).

In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children.

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By Stella Yiu, MD|2019-07-10T21:29:20-07:00Mar 16, 2011|Infectious Disease, Pediatrics, Tricks of the Trade|

Paucis Verbis: Right and posterior ECG leads

A standard 12-lead ECG can be very telling for patients with chest pain or shortness of breath. A right ventricular (RV) and posterior wall infarct, however, can present very subtly. You can obtain special right-sided (V1R-V6R) and posterior leads (V7-V9), if you are concerned. What are the indications for obtaining right-sided and posterior ECG leads?

Go to the ALiEM Cards for more resources.

Addendum 3/11/11:

Right sided ECG leads (V1R-V6R) are positioned in a mirror image fashion from the standard 12-lead precordial leads.

Posterior ECG leads (V7-V9) are applied by moving V4-V6 in the posterior positions.

By Michelle Lin, MD|2021-10-16T19:28:52-07:00Mar 11, 2011|ALiEM Cards, ECG|

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