Is this coin in the esophagus or the trachea?
The classic teaching for the Boards exam is:
Who loves relocating shoulder dislocations as much as I do? I know you do.
Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.
How can you improve your success rate in injecting into glenohumeral joint injection?
In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic.
My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
I’ve heard of underwater basketweaving, but underwater ultrasonography?
Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient’s extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient’s skin and transducer. What’s a quicker and easier way to create some distance yet preserve image quality?
Submerse both the body part and the ultrasound transducer under water.
For this “bath water technique”, start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.
This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient’s wound.
Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267
What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion.
But what we more want to know in the immediate setting is: Is this cardiac tamponade?
You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade?
Poor to average, at best. The Beck’s triad of hypotension, distended neck veins, and muffled heart sounds are important to remember … only on tests.
Think about performing a pulsus paradoxus test to see if it’s >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!
In the setting of blunt trauma, it is easily to overlook a patient’s risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.
FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.
Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.
How great would it be if you could give patients concrete numbers when you are talking about cancer risk and CT? Well, Dr. Hans Rosenberg (Univ of Ottawa) has come up with just such a table.
Using this table you can say that the risk is about “one in …”
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.