Trick of the Trade: Finding the subtle pneumothorax
Can you see the pneumothorax? Small pneumothoraces can be difficult to detect on chest xrays. Overlying ribs, other bony structures, and soft tissue can obscure subtle findings. For a patient at risk for a small pneumothorax, you can use your digital radiology PACS system to improve your ability to spot them. […]
Paucis Verbis card: Appendicitis – ACEP Clinical Policy
Appendicitis is a common presentation in the Emergency Department. Dilemmas arise when deciding whether to image patients with equivocal symptoms and WBC lab results. Given the risk of ionizing radiation with CT scans, we should ideally minimize the number of CT scans ordered in these patients without mistakenly sending patients home with an early appendicitis. A perforated appendix places the patient at risk for bowel obstruction, infertility (in women), and sepsis. […]
Trick of the Trade: Double staple gun
How do you approach the repair of scalp lacerations in a child? What factors are you considering? Is the wound suspicious for child abuse? Procedural sedation versus local anesthesia of the wound Staples versus hair apposition technique (HAT trick) for wound closure This trick of the trade pearl addresses the stapling technique for scalp laceration repair. Perhaps the child’s hair is too short for the HAT trick. […]
Paucis Verbis card: Septic Arthritis
In the workup of monoarticular arthritis, the question that emergency physicians constantly struggle over is whether the patient has a nongonococcal septic arthritis. This joint infection alarmingly damages and erodes cartilage within only a few days. This installment of the Paucis Verbis (In a Few Words) e-card series reviews the JAMA Rational Clinical Examination article which asks “Does this patient have septic arthritis?” Pooled sensitivities and likelihood ratios were calculated. These statistics are always helpful when trying to figure out the patients probability of having a septic joint. […]
Trick of the Trade: Finding the femoral vein by V-technique
I rarely access the femoral vein for central venous catheterization… except in medical or trauma resuscitations. Oftentimes in these resuscitations, there are too many people near the IJ or subclavian vein site. People are intubating, performing CPR, trying to get peripheral vein access, etc. […]
PV Card: Dermatomal and Myotomal Maps
There are some things in life which I just can't memorize and dermatomal/myotomal maps are one of them. Weird cases of peripheral neurologic symptoms have presented to the ED in the setting of trauma and no trauma. So purely for selfish reasons, I'm making my own map to have on file. This installment of the Paucis Verbis (In a Few Words) e-card series reviews Sensory and Motor Function Testing by Levels. Testing Sensory Function by Level Testing Motor Function by Level C1-C4 Spontaneous breathing C5 Shoulder abduction (deltoid) C6 Wrist extension (carpi radialis longus and brevis) C7 Elbow extension (triceps) [...]
Trick of the trade: Endotracheal tube lubrication
Does your endotracheal tube get caught up on a swollen or floppy epiglottis during insertion? Trick of the Trade: Endotracheal tube lubrication Occasionally the endotracheal tube may become “caught up” along the epiglottis. Because it is difficult to predict when this may happen, pre-lubricate the endotracheal tube cuff and tip with a thin layer of water-soluble lubricant, such as K-Y jelly. This lubricant can also minimize the degree of surface trauma to the trachea and tracheal rings as the tube passes the vocal cords.
Paucis Verbis card: Ottawa knee, ankle, and foot rules
Often times, I get called to triage to help decide whether a patient should be sent to Radiology for an initial x-ray after injuring their knee, ankle, and/or foot. After teaching one of the nurses about the Ottawa rules, she taped a list of these rules on the triage wall. This installment of the Paucis Verbis (In a Few Words) e-card series reviews Ottawa Knee, Ankle, and Foot Rules. […]
Trick of the trade: Percuss the spine in low back pain
Many patients present to the Emergency Department for low back pain. Determining whether these patients have a red-flag diagnosis can be difficult. Red flag diagnoses include: Fracture Cauda equina syndrome/ spinal cord compression Spinal infection Vertebral malignancy Almost all patients presenting with back pain, whether it be a muscle spasm or a spinal epidural abscess, will have back tenderness to some extent. So, how can you better differentiate benign from dangerous etiologies? […]
Paucis Verbis card: Vasopressors and Inotropes for Shock
The treatment of shock should focus on correcting the underlying pathophysiology. With persistent hemodynamic instability, a vasopressor and/or inotrope should be selected. Reviewing receptor physiology can help you select the best-fit agent for the patient’s clinical condition. There is an especially useful table on medication selection in the reviewed 2008 EM Clinics of North America article. This installment of the Paucis Verbis (In a Few Words) e-card series reviews Vasopressors and Inotropes for the Treatment of Shock. […]