The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications.
Go to ALiEM (PV) Cards for more resources.
Occasionally, emergency physicians see patients who present because they are unresponsive despite normal vital signs and an otherwise normal exam. You detect no drugs or alcohol on board. You suspect a psychiatric or malingering etiology, but aren’t sure. They seem non-responsive to voice and minimally responsive to very painful stimuli. Is this a case of psychogenic coma or true coma (with bilateral hemispheric dysfunction)?
What test can you do to reassure yourself that this may indeed be psychogenic coma?
When I did my residency training in Emergency Medicine and in the first few years as an attending, we regularly performed diagnostic peritoneal lavages in patients with stab wounds injuries to the abdomen. Patients also routinely went to the operating room for exploration.
Now with the evolution of CT imaging technology and more clinical studies, there is now a role for a less invasive management approach. These are the Eastern Association for the Surgery of Trauma (EAST) guidelines.
Adapted from [1]
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Burn classification and management are key skills for ED providers to remember. Depending on the prevalence of burns in your ED, it may be hard for forget the details. So here is a PV reference card on the rule of 9’s, different classifications of burns, and indications for burn unit referral.
Update (April 22, 2016): This card was updated by Dr. Christian Rose (UCSF-SFGH) to reflect current evidence that topical antibiotics and honey are IN, while silver sulfadiazine is OUT for partial-thickness burns.
Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.
Back in September of 2009 Michelle shared valuable Tricks of The Trade regarding drainage of peritonsillar abscesses. Today we revisit the topic and add two more tricks to avoid hitting “big red” a.k.a. the internal carotid artery.
A paracentesis procedure is often performed in the Emergency Department to rule a patient out for spontaneous bacterial peritonitis (SBP).
This installment of the Paucis Verbis (In a Few Words) e-card series provides an evidence-based review of the literature on topics related to the paracentesis procedure. Especially helpful is the pooled data of likelihood ratios. Like most everything in medicine, a lab test should be used in conjunction with your pretest probability in clinical decision making, and LR’s help with with this.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Can you see the pneumothorax?
Small pneumothoraces can be difficult to detect on chest xrays. Overlying ribs, other bony structures, and soft tissue can obscure subtle findings. For a patient at risk for a small pneumothorax, you can use your digital radiology PACS system to improve your ability to spot them.