Paucis Verbis card: Skipping the CT prior to LP for meningitis

With increasing awareness of CT’s irradiation risk, I thought I would review a classic 2001 article from the New England Journal of Medicine. Head CT’s previously were commonly performed prior to all lumbar punctures (LP) to rule-out meningitis. When can you safely go straight to an LP without imaging?

Caveat: This review only applies to those patients in whom you suspect meningitis. This does not apply to those being worked up for subarachnoid hemorrhage.

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By Michelle Lin, MD|2021-10-19T19:36:53-07:00Apr 23, 2010|ALiEM Cards, Neurology, Radiology|

Paucis Verbis card: Early goal directed therapy

One of the landmark studies in sepsis was conducted by Dr. Emanuel Rivers (Henry Ford) and published in the New England Journal of Medicine in 2001. By managing patients with severe sepsis and septic shock with an “early goal directed therapy” approach, there was an absolute risk reduction of 16%. Furthermore, the number needed to treat to save a life was 6 patients!

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Early Goal Directed Therapy algorithm. The layout is borrowed from a Cleveland Clinic Foundation (CCF) flowchart.

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. [PubMed]

By Michelle Lin, MD|2021-10-19T18:50:19-07:00Apr 16, 2010|ALiEM Cards, Infectious Disease|

Trick of the Trade: Retracting Swollen Eyelids

Eyelids can become edematous from blunt trauma and local inflammation, making it difficult to visualize the orbit. How do you retract the eyelids, if you don’t have the fancy ophthalmology eyelid retractors?

Trick of the Trade

Use a Q-tip

I thought of this idea when I was rolling up a projector screen in a conference room. Why can’t we use this rotational concept on the upper eyelid to retract it? Rest the Q-tip on the surface of the upper eyelid and slowly rotate the Q-tip to “roll” the eyelid out of the way.

Below are a series of photos of a woman with eyelid swelling from conjunctivitis. This technique provides a relatively painless way to retract the eyelid without placing pressure on the orbit itself. Although the images look like I am merely lifting the eyelid using the Q-tip, I am actually twirling the Q-tip.

Consent and photographs taken by Lourdes Adame
(Visual Aid Project member)

By Michelle Lin, MD|2019-01-28T23:42:58-08:00Apr 14, 2010|Ophthalmology, Tricks of the Trade|

Trick of the trade: Eye irrigation setup

Morgan lens are placed to irrigate eyes splashed with foreign substances. Whenever I place them, images of horror and torture movies arise. Especially for patients who aren’t used to having something touch their eyes like contact lens, the Morgan lens gives them the heeby-jeebies.

For the past several years, I’ve stopped using Morgan lens and have started using something that all Emergency Departments have — nasal cannulas for oxygen administration. They are perfect for high-volume eye irrigation.

Instead of attaching the nasal cannula to an oxygen port, attach it to the end of IV tubing, which in turn is attached to a 1 liter normal saline bag. The IV tubing fits snuggly into the nasal cannula tubing.

Rest the nasal cannula prongs over the patient’s nasal bridge to irrigate the eyes.
Then open up the flood gates!
To avoid a huge deluge of fluid onto the patient and floor, be sure to have a way to catch the fluid. Some place multitudes of towels around the patient’s head to absorb the fluid.
As an alternative solution to towels, I like Dr. Stella Yiu’s (Univ of Toronto) adaptation of my cut-out basin approach for irrigating scalp wounds. To avoid overflow spillage, she rests a Yankauer suction tip at the bottom of the basin to collect the irrigation fluid.

By Michelle Lin, MD|2019-02-19T18:53:53-08:00Apr 7, 2010|Ophthalmology, Tricks of the Trade|

Paucis Verbis card: ABG interpretation

I have yet to find a better arterial blood gas interpretation review article than the 1991 Western Journal of Medicine summary by Dr. Rick Haber.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews ABG Interpretation. The recent addition of an ABG machine in our ED has made a tremendous difference in our ability to care for undifferentiated patients. This is a refresher in making heads and tails of mixed acid-base disorders.

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Haber R. A practical approach to acid-base disorders. West J Med. 1991;155(2):146-151. [PubMed]

By Michelle Lin, MD|2021-10-19T18:53:19-07:00Apr 2, 2010|ALiEM Cards, Endocrine-Metabolic, Pulmonary|

Great teaching video: Corneal FB removal

Patients often come into the ED for eye pain. One of my favorite procedures is removal of a small foreign body embedded in the cornea. There is a great instructional video on removing such foreign bodies and the use of a ophthalmic burr on removing rust rings.

The video recommends using either a 30-gauge or 18-gauge needle. I prefer the less innocuous-looking 29-gauge insulin/TB needle. Can you imagine someone coming towards your eye with a large 18-gauge needle?!

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By Michelle Lin, MD|2019-01-28T23:44:07-08:00Mar 30, 2010|Ophthalmology|

Paucis Verbis card: Angioedema

Recently, a patient presented with angioedema after starting taking an ACE-inhibitor. There was upper lip swelling, similar appearing to the case above. He also experience a hoarse voice. Before the advent of fiberoptic nasopharyngoscopy, it was assumed that there may be laryngeal edema. Fortunately, using technology, we were able to visualize a normal epiglottis and a grossly normal laryngeal anatomy.

Should patient with angioedema be admitted?

The 1999 study on admission guidelines, of course, should be weighed with physician judgment and the patient’s social issues. The study was retrospective and the results should be weighed carefully. For me, generally I admit all cases involving intraoral structures and progressively worsening extraoral angioedema. I also perform fiberoptic nasopharyngoscopy on all patients with voice changes.

PV Card: Angioedema

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Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Temiño V, Peebles R. The spectrum and treatment of angioedema. Am J Med. 2008;121(4):282-286. [PubMed]

By Michelle Lin, MD|2021-10-19T18:55:31-07:00Mar 26, 2010|ALiEM Cards, Allergy-Immunology, ENT|