• 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? […]

Paucis Verbis card: Workup for first-time seizure

By |Categories: ALiEM Cards, Neurology|

How do you workup adult patients who present with a new-onset seizure and now neurologically back to normal? There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches. […]

  • Suture

Paucis Verbis card: Suture Materials

By |Categories: ALiEM Cards|Tags: |

Suturing is a common procedure performed in the ED, but we too often forget about the nuances of different suture materials. We get set in our practice patterns. This changed when our ED got the fast-absorbing gut suture for surface wounds, especially for pediatric patients. This makes a return visit for suture removal unnecessary because they quickly become absorbed over time. Increasingly, I have observed plastics surgeons using these for surface wound closure of the face and hands. Has anyone else used absorbable sutures on the skin for wound closure? […]

  • Contact Lens Yellow

Tricks of the Trade: Finding the wandering contact lens

By |Categories: Ophthalmology, Tricks of the Trade|

Contact lens wearers are familiar with the phenomenon of the wandering lens. What should you do if you can’t visualize the contact lens of a patient, who presents with a “lost contact lens” in the eye? You have the patient look in all directions and you evert the eyelid, but still no contact lens can be found. The patient swears that it’s there because of the painful foreign-body sensation. […]

  • CT SAH

Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics

By |Categories: ALiEM Cards, Neurology|

In Wednesday’s post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada. We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it’s difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don’t miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache. […]

Paucis Verbis card: Cervical spine imaging rules

By |Categories: ALiEM Cards, Orthopedic, Trauma|

There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice. The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients. Sensitivity (%) Specificity (%) NEXUS 99.6 12.6 CCR 99.4 45.1 […]

  • Self reflection

Trick of the Trade: Self-Reflection

By |Categories: Medical Education, Tricks of the Trade|

  After a shift, we often review the day’s case with our learners. We sometimes ask them to self-reflect. I often used Demian’s ‘Plus/Delta’ approach and ask ‘What did you like /what would you change?’ This approach works well mostly. But, when the answer is ‘I don’t think I would change anything’, it is hard to target teaching and feedback to the learner’s need. […]

  • Dysphagia

Paucis Verbis card: Dysphagia

By |Categories: ALiEM Cards, Gastrointestinal|

Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician. […]