• Ketamine vial

Hot off the press: Clinical practice guideline for ketamine in the ED

By |Categories: Pediatrics, Tox & Medications|

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction. Hhhmmmm…how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions! Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was [...]

  • Pneumonia RUL

Paucis Verbis: Pneumonia risk stratification tools

By |Categories: ALiEM Cards, Pulmonary|

Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score. Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)? […]

  • Suicidal frown depressed depression

Paucis Verbis: Assessing patients with suicidality in the ED

By |Categories: ALiEM Cards, Psychiatry|

Dr. Rob Orman emailed me last week about creating a pocket card on Suicide Risk Stratification. In many community ED’s, risk assessment is done by the emergency physician. I’m lucky where I work, because we have a 24/7 psychiatric ED, which consults on suicidal patients in the “medical ED”. In the end, assessment is primarily based on physician judgment, because there’s no great clinical decision tool, rules, or scores to assess risk. Rob has created his own mnemonic to help you ask the right questions in assessing a suicidal patient. This is a sneak peek into a larger article that [...]

Trick of the Trade: Conveying risk for postexposure prophylaxis

By |Categories: Infectious Disease, Tricks of the Trade|

A health care worker hurried in to the ED after being poked with a needle. ‘It was an old 18G needle with dried blood’, she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, ‘What does very low risk mean?’ Is there another way to covery risk for patients? […]

  • Snowpocalypse

Paucis Verbis: Management of Accidental Hypothermia

By |Categories: ALiEM Cards, Environmental|

With all of the amazing, sunny weather here in California, I feel (briefly) terrible for all those braving the snowpocalyptic conditions across the United States. So, in honor of all those bundled up and shivering, I wanted to review the management of accidental hypothermia. Tip: Avoid jostling the hypothermic patient too much because of myocardial irritability. Don’t send your patient into an arrhythmia. […]

  • EKG leads hairy chest

Trick of the Trade: Getting an EKG on Chewbacca

By |Categories: ECG, Tricks of the Trade|

  Patients with a hairy chest may require little patches of hair to be shaved when applying EKG leads. This allows the leads to stick firmly to the chest. Loose leads will result in either an artifactual signal or no signal at all on the EKG machine. How can you obtain an EKG without shaving little patches on the patient’s chest? […]

  • Shoulder pain

Paucis Verbis card: The Shoulder Exam

By |Categories: ALiEM Cards, Orthopedic|

How many times have you had to look up the shoulder exam maneuvers for patients with acute shoulder pain? I don’t know why I just can’t seem to remember these. This Paucis Verbis card is a quick reference card to remind you of the most common techniques. Thanks to Jenny for the idea. […]

  • Status Epilepticus

Paucis Verbis card: Generalized Convulsive Status Epilepticus

By |Categories: ALiEM Cards, Neurology|

How do you manage patients who present in status epilepticus, knowing that “time is CNS function”? The longer patients remain seizing, the greater their morbidity and mortality. Did you know that one study showed that 48% of their patients who presented in generalized convulsive status epilepticus (GCSE) had subtle persistent GCSE on EEG, despite no clinical evidence of overt seizure activity? That’s scary. Do you send off a serum tricyclic toxicology screen for all your patients with GCSE? Because of the prevalence of TCA overdoses locally, our Neurology consultants definitely order it. We are picking up a surprising number of [...]

  • hyperpronation

Tricks of the Trade: Nursemaid elbow reduction

By |Categories: Orthopedic, Pediatrics, Tricks of the Trade|Tags: |

We’ve all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? What if nothing happens? Is there an alternative technique to reducing a nursemaid elbow? […]