• ABG radial

PV card: VBG versus ABG

By |Categories: ALiEM Cards, Endocrine-Metabolic, Pulmonary|

You obtain a venous blood gas (VBG) on a patient with a COPD exacerbation because you are concerned about hypercarbia. You get a value of 55 mmHg. How correlative is that compared to an arterial blood gas (ABG). There has been a lot of literature on how well the pH correlates between the ABG and VBG but what about pCO2? A small study (n=89) from 20121 found that with a cutoff of pCO2 < 45 mmHg, the venous pCO2 is 100% sensitive in ruling out arterial hypercarbia. When the pCO2 was ≥ 45 mmHg, the VBG was less correlative. Below is [+]

  • ultrasound dvt

PV card: Diagnosis of DVT (ACCP guidelines)

By |Categories: ALiEM Cards, Cardiovascular|

A patient presents with an asymmetric leg with trace pitting edema in the affected leg. What is your diagnostic approach to such a patient? What is the role of D-dimer and ultrasound (U/S)? Does this match the 2012 American College of Chest Physicians (ACCP) guidelines? The first step is to determine your patient's pretest probability because the recommendations vary based on risk. I can tell you that many ED patients come in with a Wells score of 1-2, which places them in the "moderate pretest probability" category. There are 2 approaches you can take based on the availability of resources at [+]

  • Abscess Packing Hand

Trick of Trade: Incision and loop drainage using tourniquet

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

The technique for abscess drainage traditionally is incision and drainage (I&D). In August 2012, I wrote about incision and loop drainage (I&LD), which it seems has gained popularity over time with similar outcomes. This technique involves using a sterile vascular loop, which is thin and long enough to form a loose knotted loop. The video below by Dr. Rob Orman reviews the steps. But, what if you don’t have a vascular loop in the ED? [+]

Patwari Academy videos: Low risk chest pain

By |Categories: Cardiovascular, Patwari Videos|Tags: |

One of the most common complaints in the Emergency Department is chest pain. Is it something serious? How do I risk-stratify patients with potential acute coronary syndrome? What should I be thinking of and not missing? Rahul goes over the low-risk chest pain patient in 2 great, short teaching videos, based partly on the 2010 AHA/ACC Guideline for ACS risk stratification. [+]

Diminishing Returns: The MIC Creep Dilemma with Vancomycin

By |Categories: Tox & Medications|

The story of vancomycin all started when a missionary from Boreno sent a sample of dirt to a friend at Eli Lilly. The compound isolated had activity against most gram positive organisms. In fact, it got its name from the word ‘vanquish.’ Vancomycin was FDA-approved in 1958. [1] Vancomycin is still a powerful tool against gram positive organisms, but there are some important learning points for using it properly in the critically ill ED patient. [+]

Trick of Trade: Rule of 10’s for burn fluid resuscitation

By |Categories: Trauma, Tricks of the Trade|

  A patient presents with burns to both his arms, chest, and abdomen (anteriorly only) from a flash fire. That’s about 27% total body surface area (TBSA). So how much IV fluid should be given? Be aware of a phenomenon known as “fluid creep”, where patients actually get WAY too much IV fluids than they should, which can cause delayed complications such as ACS, pulmonary edema, and compartment syndrome. Don’t forget that patients often get a lot of IV fluids in the prehospital setting, which should also be factored in. [+]

    Shuhan He, MD

    Shuhan He, MD

    ALiEM Senior Systems Engineer;
    Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
    Massachusetts General Hospital;
    Chief Scientific Officer, Conductscience.com
    Shuhan He, MD