• cpr

New 2010 ACLS guidelines from the AHA, ERC, and ILCOR

By |Categories: Cardiovascular, Guideline Review|

Last month the AHA, ERC, and ILCOR released the 2010 Resuscitation Guidelines. They build on the 2005 and previous guidelines and continue the trend towards more, higher quality, uninterrupted CPR. The complete summary and recommendations are published in Circulation and are available for free. Here is my summary for you! […]

  • Paronchia splint

Trick of the Trade: Toe paronychia splinting

By |Categories: Tricks of the Trade|Tags: |

Ingrown toenails, or paronychias, are usually exquisitely painful and a bit gnarly when they present to you in the Emergency Department. Dr. Stella Yiu described toenail splinting techniques using steristrips or dental floss. The purpose of splinting is to prevent the toenail from growing back into the lateral nail fold. This assumes a relatively mild-to-moderate case. Often simple elevation of the nail out of the lateral nail fold (under digital block anesthesia) is all that is needed to treat a paronychia. Pus is often released with this maneuver. What do you do for more severe cases when you have to [...]

  • Intravag Transducer

Trick of the Trade: Ultrasound-guided supraclavicular central line

By |Categories: Tricks of the Trade, Ultrasound|Tags: |

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.  […]

  • Sgarbossa criteria

Paucis Verbis: Sgarbossa’s Criteria with LBBB

By |Categories: ALiEM Cards, Cardiovascular, ECG|

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). […]

  • Child Cough

Paucis Verbis card: Algorithm for suspected pertussis in pediatrics

By |Categories: ALiEM Cards, Infectious Disease, 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. […]

  • atomizer

Tricks of the trade: Intranasal fentanyl for pediatric patients

By |Categories: Pediatrics, Tricks of the Trade|

 Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control. Trick of the Trade Intranasal (IN) fentanyl Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:It is imperative that the drug be administered in a nebulized form using an atomizer device -- one half the [...]

  • Broselow tape

Paucis Verbis card: Pediatric weight-based reference (5-34 kg)

By |Categories: ALiEM Cards, Pediatrics|

The foundation in any pediatric resuscitation is the length-based estimation of the patient’s lean body weight. Once determined, equipments and medications are sized and dosed, respectively, according to that weight. You can use electronic resources such as PEMSoft (Pediatric Emergency Medicine Software) or the more traditional paper-based Broselow tape. […]

  • BVM placement

Trick of the trade: Face mask ventilation in edentulous patients

By |Categories: Tricks of the Trade|Tags: |

Can you imagine trying to bag-valve-mask ventilating this patient without teeth? Edentulous patients can cause BVM problems because air tends to leak out the sides of the mouth, because the cheeks don’t contact the mask as well. You can do a jaw-thrust and/or place an oropharyngeal airway to help. What else can you do? […]