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|

Trick of the Trade: Website resource on HIV medications

At our department’s first annual UCSF High Risk Hawaii Conference 2 weeks ago, Dr. Rachel Chin taught about complications from all of the HIV drugs on the market now. It’s a virtual alphabet soup: EFV, TDF, FTC, oh my. How do you keep track of them all?

(more…)

By Michelle Lin, MD|2019-01-28T23:04:30-08:00Mar 2, 2011|Infectious Disease, Social Media & Tech, Tricks of the Trade|

Hot off the press: Clinical practice guideline for ketamine in the ED

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.

Hhhmmmm…how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.¹

(more…)

By Fred Wu, MHS, PA-C|2017-02-28T09:43:19-08:00Mar 1, 2011|Pediatrics, Tox & Medications|

Paucis Verbis: Pneumonia risk stratification tools

Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score.

Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)?

PV Card: Risk Stratification Scoring Tools in Pneumonia

Go to the ALiEM Cards for more resources.

By Michelle Lin, MD|2021-10-16T19:31:04-07:00Feb 25, 2011|ALiEM Cards, Pulmonary|

Paucis Verbis: Assessing patients with suicidality in the ED

Dr. Rob Orman emailed me last week about creating a pocket card on Suicide Risk Stratification. In many community ED’s, risk assessment is done by the emergency physician. I’m lucky where I work, because we have a 24/7 psychiatric ED, which consults on suicidal patients in the “medical ED”.

In the end, assessment is primarily based on physician judgment, because there’s no great clinical decision tool, rules, or scores to assess risk. Rob has created his own mnemonic to help you ask the right questions in assessing a suicidal patient. This is a sneak peek into a larger article that Rob is planning to unleash on the world on suicide assessment. Based on his review of the literature and own clinical experience, the mnemonic is: TRAAPPED SILO SAFE.

TRAAPPED SILO

“Risk factors” which increase a patient’s risk for committing suicide in the near future.

SAFE

“Protective factors”which decrease a patient’s risk for committing suicide in the near future.

PV Card: Risk Stratification of Suicide

Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-16T19:32:00-07:00Feb 18, 2011|ALiEM Cards, Psychiatry|

Trick of the Trade: Serial lactate measurements in sepsis?

Does your Emergency Department have computerized spectrophotometric catheters to measure continuous central venous oxygen saturation (ScvO2) in early goal directed therapy (EGDT) for severe sepsis? That’s what was used in the original Rivers’ EGDT study.

I’ve never even seen one before.

(more…)

By Michelle Lin, MD|2019-01-28T23:05:12-08:00Feb 16, 2011|Infectious Disease, Tricks of the Trade|

Trick of the Trade: Conveying risk for postexposure prophylaxis

A health care worker hurried in to the ED after being poked with a needle.

‘It was an old 18G needle with dried blood’, she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, ‘What does very low risk mean?’

Is there another way to covery risk for patients?

(more…)

By Stella Yiu, MD|2019-02-19T18:21:27-08:00Feb 9, 2011|Infectious Disease, Tricks of the Trade|