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Paucis Verbis: Identifying toxidromes by vital signs

A middle-age woman presents to the Emergency Department with altered mental status after having ingested a drug. Is it an opioid? Is it an antihistamine?

The key is to pay close attention to the vital signs. They are often the clue to the mystery. I found this great table from EM Clinics of North America by Dr. Timothy Erickson from 2007. I can’t imagine how long it took for him to create all these mnemonics. I’ll never remember these mnemonics, but they’re fun to read nonetheless.

PV Card: Toxidromes by Vital Signs


Go to ALiEM (PV) Cards for more resources.

By |2021-10-17T09:22:42-07:00Nov 19, 2010|ALiEM Cards, Tox & Medications|
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Trick of the Trade: Ultrasound-guided supraclavicular central line

SupraclavicularPositionsmEmergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots

Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer. 

By |2016-11-11T19:00:20-08:00Nov 10, 2010|Tricks of the Trade, Ultrasound|
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Paucis Verbis: Sgarbossa’s Criteria with LBBB

EKG_LBBB

It is difficult to determine if a patient with a left bundle branch block (LBBB) has an acute myocardial infarction (AMI) because ST segments are “appropriately discordant” with the terminal portion of the QRS. That means if the QRS complex is negative (or downgoing), the ST segment normally will be positive (or elevated). Similarly if the QRS complex is positive (or upgoing), the ST segment will be negative (or depressed).

PV Card: Sgarbossa’s Criteria

In 1996, Sgarbossa et al looked through the GUSTO-1 trial patients with LBBB and AMI. They derived 3 criteria which may help diagnose the “hidden” AMI. The criteria are:

1. ST elevation ≥ 1 mm concordant with QRS complex (most predictive of AMI of the 3 criteria)
2. ST depression ≥ 1 mm in lead V1, V2, or V3
3. ST elevation ≥ 5 mm where discordant with QRS complex

Use these criteria with caution though. None of these criteria are perfect. They are to help you risk-stratify. For instance, criteria #3 (ST elevation ≥ 5 mm) can exist in asymptomatic patients with LBBB because of concurrent left ventricular hypertrophy and high voltages.

Thanks to Tom Bouthillet at ems12lead.com for the useful illustration above.
Go to ALiEM (PV) Cards for more resources.
By |2021-10-17T09:25:38-07:00Nov 5, 2010|ALiEM Cards, Cardiovascular, ECG|
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Paucis Verbis card: Algorithm for suspected pertussis in pediatrics

ChildCough

To treat for pertussis or not?

In the setting of the current pertussis epidemic in California, each kid with a cough sparks constant debate about whether to treat with azithromycin or not. Finally, thanks to my friends Dr. Andi Marmor and Dr. Shon Agarwal Jain (UCSF Pediatrics faculty), there’s a great algorithm to help you answer the question. I have found this algorithm extremely helpful.

You basically start by risk-stratifying by age and pertussis immunization status. For instance, if the patient is 6 months of age AND unimmunized), then follow the algorithm listed as “High Risk for Pertussis”.

PV Card: Suspected Pertussis in Pediatric Patients


Go to ALiEM (PV) Cards for more resources.

By |2021-10-17T09:28:20-07:00Oct 29, 2010|ALiEM Cards, Infectious Disease, Pediatrics|
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