Trick of the Trade: Corneal reflex test

The corneal reflex test (blink test) examines the reflex pathway involving cranial nerves V and VII. Classically the provider lightly touches a wisp of cotton on the patient’s cornea. This foreign body sensation should cause the patient to reflexively blink.

This maneuver always makes me a little worried about causing a corneal abrasion, especially if you are examining a very somnolent patient. You are wondering — Is there no blinking because you’re not touching the cornea hard enough? You apply harder pressure but still no blink. You repeat the test and now the patient finally blinks. That’s 3 times you’ve just scraped against the cornea.

What’s an alternative approach?

(more…)

By Michelle Lin, MD|2016-11-11T18:58:00-08:00Apr 20, 2011|Neurology, Tricks of the Trade|

Paucis Verbis: Dental trauma

How cool is this — I have talented emergency physicians contributing Paucis Verbis card content! This week features excellent pearls on Dental Trauma by Dr. Hans Rosenberg (University of Ottawa). Here’s his recent article in Annals of EM on reimplantation of avulsed teeth.¹

PV Card: Dental Trauma

<span data-mce-type="bookmark" style="display: inline-block; width: 0px; overflow: hidden; line-height: 0;" class="mce_SELRES_start"></span>
Go to ALiEM (PV) Cards for more resources.

Reference

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. [PubMed]

By Michelle Lin, MD|2021-10-15T11:15:07-07:00Apr 15, 2011|ALiEM Cards, Dental|

Trick of the Trade: Oblique CXR to look for pneumothorax

Supine chest xrays have an extremely low sensitivity (12-24%) in detecting pneumothoraces. Because a pneumothorax layers anteriorly on an AP CXR film, the xray beam is perpendicular rather than tangential to the pneumothorax edge. This makes visualizing a small to moderate sized pneumothorax extremely difficult. So you are left to look for indirect signs such as a deep sulcus at the costophrenic angle or subcutaneous air. I’m often surprised at how large of a pneumothorax can be missed on CXR based on CT imaging. The image to the right shows a large left-sided pneumothorax on CT.

What if you have an equivocal bedside ultrasound result in looking for a pneumothorax, and the patient is too unstable to go to CT?

(more…)

By Michelle Lin, MD|2019-02-19T18:08:06-08:00Apr 13, 2011|Radiology, Tricks of the Trade|

Paucis Verbis: AMI and ECG Geography

Sometimes a picture is worth MORE than a 1000 words. Such is the case of the above illustration that I saw on the Life In The Fast Lane blog. When I first saw it, I knew that I immediately had to find out who made the graphic. It turns out it is the multitalented Dr. Tor Ercleve, who is an emergency physician at Sir Charles Gairdner Hospital and an established medical illustrator.

This graphic demonstrates the EKG findings for the various types of acute MI’s as broken down by coronary vascular anatomy (right coronary artery, left circumflex artery, left anterior descending artery). This detailed illustration won’t be readable in print form but is great in digital format on your mobile device.

Thanks, Tor!

[PDF]

Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-15T11:17:43-07:00Apr 8, 2011|ALiEM Cards, Cardiovascular, ECG|

Trick of the Trade: Check pupillary constriction with ultrasound

In some trauma patients with head and face trauma, you will need to check their pupillary response to light. Severe periorbital and eyelid swelling, however, make this difficult. You want to minimize multiple attempts to retract the eyelids because of the risk of a ruptured globe. What’s a minimally painful and traumatic way to check for pupillary constriction?

(more…)

By Michelle Lin, MD|2019-01-28T22:50:28-08:00Apr 6, 2011|Ophthalmology, Tricks of the Trade, Ultrasound|

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

<span data-mce-type="bookmark" style="display: inline-block; width: 0px; overflow: hidden; line-height: 0;" class="mce_SELRES_start"></span>
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|2026-06-16T16:03:12-07:00Apr 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?

(more…)

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