Trick of the Trade: Ultrasound-guided supraclavicular central line

Emergency 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.

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By Michelle Lin, MD|2016-11-11T19:00:20-08:00Nov 10, 2010|Tricks of the Trade, Ultrasound|

Paucis Verbis: Sgarbossa’s Criteria with 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 Michelle Lin, MD|2021-10-17T09:25:38-07:00Nov 5, 2010|ALiEM Cards, Cardiovascular, ECG|

Trick of the Trade: Legg Maneuever for shoulder dislocation

There are many ways to relocate a shoulder dislocation. Most of these ways require procedural sedation. What if the risks of procedural sedation outweigh the risks? What alternative maneuver can you try, which only requires parenteral pain medications +/- an intra-articular lidocaine?

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By Michelle Lin, MD|2016-11-11T19:00:23-08:00Nov 3, 2010|Orthopedic, Tricks of the Trade|

Paucis Verbis card: Algorithm for suspected pertussis in pediatrics

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

Retinal detachment on ultrasound

I just wanted to revisit the Trick of using bedside ultrasonography to diagnose retinal detachments. Be sure to use plenty of ultrasound gel and use the linear tranducer.

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By Michelle Lin, MD|2019-01-28T23:21:35-08:00Oct 19, 2010|Ophthalmology, Tricks of the Trade, Ultrasound|

Paucis Verbis card: C3-C7 spinal fractures

$Fig9E Fx FlexTear anatomy cervical spine fracture$

This is the second Paucis Verbis card on cervical spine fractures. Part 1 covered C1 and C2 fractures. This card covers the lower cervical spine fractures. These two tables are part of my chapter on “Spine and Spinal Cord Injury” in the textbook Emergency Medicine by Dr. Jim Adams (Northwestern EM Chair).

PV Card: C3-C7 Fractures and Injuries

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Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-18T09:59:44-07:00Oct 8, 2010|ALiEM Cards, Orthopedic|

Trick of the trade: Discounted medications at pharmacies

Many times, patients who we deem as “noncompliant” with medications may actually be financially unable to afford medications that we prescribe them. Thanks to Amy Kinard, I just learned about this great new website where you can find pharmacies with amazing discounts for common medications.

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By Michelle Lin, MD|2026-06-16T16:03:29-07:00Oct 6, 2010|Tox & Medications, Tricks of the Trade|