• suboxone

Suboxone and the Emergency Physician: Get Waivered Training

By |Categories: Public Policy, Tox & Medications|

Clinical scenario: A 56-year-old male with a past medical history of opioid use disorder presents to the emergency department with acute on chronic right lower flank pain. The patient states the pain was exacerbated while shoveling snow over the weekend and worsens with movement. He feels nauseous but denies any chest pain, shortness of breath, vomiting, abdominal pain, or pain with urination. He denies any history of kidney stones, recent surgeries, and recent injuries. He does not smoke cigarettes, but does drink alcohol almost daily. His pain actually first started 2 months ago due to a work incident, for [+]

SAEM Clinical Images Series: Found Down

By |Categories: Cardiovascular, Critical Care/ Resus, Pulmonary, Radiology, SAEM Clinical Images|

A 67-year-old caucasian male experiencing homelessness was “found down” in a parking lot. EMS reported that he had a GCS of 6 with a systolic blood pressure in the 80’s, finger stick glucose of 100, and no response to intranasal naloxone. He was intubated in the field and arrived to the emergency department unresponsive with a BP of 95/60, HR 125, T 38°C, and O2 Sat 100%. Hemodynamic stabilization was achieved with central venous access, and laboratory and imaging studies for the evaluation of altered mental status ensued.   General: Disheveled male [+]

SAEM Clinical Images Series: A Backpacker’s Rash

By |Categories: Dermatology, SAEM Clinical Images|

A 33-year-old female presented with a progressively worsening rash for one week. The patient just finished hiking the John Muir Trail, a backpacking trip that encompassed three weeks and over 240 miles. On the last days of the trip, the patient started to develop a severely itchy, red rash on both feet. She tried using a topical anti-fungal, which seemed to make the rash worse. She now has swelling and difficulty walking. The rash does not involve the hands or other parts of the body. She denies fever, open wounds, nausea, vomiting, or systemic symptoms, [+]

Trick of the Trade: Getting the last bit of ultrasound gel from the bottle

By |Categories: Tricks of the Trade, Ultrasound|

It’s a busy shift and you need to perform a bedside ultrasound on a patient’s belly to rule out cholecystitis, when you realize that the ultrasound gel bottle is nearly empty. No matter how many times you vigorously shake the bottle, it’s impossible to get the viscous gel out. In a pinch, you could use hand sanitizer, sterile lubricant, or even water as a substitute for gel. Or you could run to the storage room on the other side of the busy department to grab a new bottle. Or… Trick of the Trade Use centrifugal force to move the [+]

  • em pharm pearls glucose d50 rise

EM Pharm Pearls: Estimated rise in blood glucose concentration with dextrose administration

By |Categories: EM Pharmacy Pearls, Endocrine-Metabolic|

A common question is how much should we expect the blood glucose concentration to increase after dextrose 50% (D50) administration. Fortunately, there is an answer from 3 studies. Balentine JR, Gaeta TJ, Kessler D, Bagiella E, Lee T. Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Acad Emerg Med. 1998;5(7):691-694. doi:10.1111/j.1553-2712.1998.tb02487.x PMID 9678393 Population: Healthy volunteers in the ED Intervention: 25 gm (1 ampule of D50) Result: Mean increase of 162 mg/dL at 5 min. Glucose concentrations returned to baseline by 30 minutes. Murthy MS, Duby JJ, Parker PL, Durbin-Johnson BP, [+]

Trick of the Trade: A “Fiberbougie” through a supraglottic airway device (King tube)

By |Categories: Critical Care/ Resus, Tricks of the Trade|Tags: |

Resuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success [3]. Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could [+]

  • mallet finger

SplintER Series: Stop! Hammer Time

By |Categories: Expert Peer Reviewed (Clinical), Orthopedic, SplintER|

A 54-year-old female presents to the emergency department with 3rd and 4th right finger pain after “jamming” them a week ago. She was reaching to tap someone on the shoulder and they backed into her hand forcing her fingers into flexion. She has swelling and pain at the distal interphalangeal (DIP) joint of her 3rd and 4th digits on the right and cannot extend the digits at the DIP joint. An x-ray of the right hand was obtained and is shown above (Figure 1: Lateral radiographs of the right hand. Author’s own images). [+]

ALiEM AIR Series | Non-ACS Cardiology 2022 Module

By |Categories: Approved Instructional Resources (AIR series)|

Welcome to the AIR non-ACS cardiology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to non-ACS cardiology emergencies in the Emergency Department. 12 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 5 AIR and 7 Honorable Mentions. We recommend programs give 6 hours (about 30 minutes per article) of III credit for this module. AIR Stamp of Approval and Honorable Mentions In an effort to [+]

Trick of the Trade: Don’t fight the ultrasound cord for peripheral IV access

By |Categories: Tricks of the Trade, Ultrasound|

Ultrasound-guided IVs require hand-eye coordination and fine movements of probe in Goldilocks fashion. Apply too much pressure, and the vein in question is compressed. Slide a little to the right, and now it's out of the window. Something that practitioners don't think about is the tension from the cord. If left to its own devices, the cord will tug on the probe, making the probe harder to steer and handle, especially for those tiny veins. Trick of the Trade: Reduce cord tension Have the patient grasp the cord! This makes them an active participant. Usually, if they are awake and [+]