Paucis Verbis: Blunt cardiac injury
Do you always get a troponin for patients who sustain blunt chest trauma? Hopefully your answer is no. Of note, it is also NOT indicated as a screening test for those in whom you suspect a blunt cardiac injury (BCI). It can be normal in the setting of arrhythmias and it can be falsely elevated in the setting of catecholamine release or reperfusion injury from hypovolemic shock. The initial screening test should include an ECG and a FAST ultrasound exam. If you have abnormal ECG findings, then a troponin is warranted (in addition to hospital admission). Below summarizes a suggested [+]
Tricks of the Trade: Valsalva maneuver by using a 10 cc syringe
Last week, Dr. David Johnson shared his trick to elicit a Valsalva maneuver out of his patient. Here’s another trick that I saw one of our EM residents use in an attempt to break a SVT rhythm. [+]
Paucis Verbis: Toxic alcohols – Isopropyl alcohol
Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol, methanol), this Paucis Verbis card focuses on isopropyl alcohol toxicity, which is commonly found in rubbing alcohols. In this toxic alcohol, fomipezole is actually NOT indicated because you want to have alcohol dehydrogenase convert the toxic parent compound (isopropyl alcohol) into the nontoxic metabolite (acetone). Note that these are merely guidelines and you should tailor management plans with your toxicologist and nephrologist. PV Card: Isopropyl Alcohol Toxicity Adapted from [1, 2] Go to ALiEM (PV) Cards for more resources. References Kraut J, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, [+]
Trick of the Trade: Valsalva maneuver by pressing on the abdomen
A patient presents to triage in rapid SVT rhythm. While you are trying to get an IV in the patient and drawing up adenosine, you have the patient perform a Valsalva maneuver to see if increased vagal tone itself will break the arrhythmia. Unfortunately, she is unable to understand your instructions. [+]
Paucis Verbis: Toxic alcohols – Methanol
Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol), this Paucis Verbis card focuses on methanol toxicity. Useful are the American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis. I redrew the flowchart based on what’s relevant to the ED in the initial stages. [+]
Trick of the Trade: "Punch out" the foreign body
A patient re-presents to the Emergency Department with a foreign body sensation in his heel after stepping on a broken window. Despite a negative xray and bedside ultrasound yesterday, the patient still believes that a small foreign body is still in there. You are unable to find a foreign body despite excising the overlying skin with a scalpel and exploring with forceps. [+]
Paucis Verbis: Toxic alcohols – Ethylene glycol
Following last week's Paucis Verbis card on calculating the osmolal gap, here is the first installment of the Toxic Alcohols cards. First up -- ethylene glycol. There are useful American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis. Here's a quick review of the metabolism of the different toxic alcohols. The parent compounds for ethylene glycol and methanol are innocuous and the metabolites are toxic. PV Card: Ethylene Glycol Toxicity Adapted from [1-3] Go to ALiEM (PV) Cards for more resources. See Dr. Leon Gussow's great review on The Poison Review and tips [+]
Trick of the Trade: Hair tourniquet release
A 3 month old baby presents with distal erythema and swelling of one of her toes. A hair tourniquet is identified. Typically one can try manually unwrapping the tourniquet using forceps, but often only part of the tourniquet can be removed. The distal toe remains swollen and erythematous with delayed capillary refill. As demonstrated by the image above, it can be difficult to identify the hair because of the edema and the thin nature of the hair (especially if the same as the patient’s skin color). In a 2006 review of hair tourniquets in the Annals of Plastic Surgery, they [+]
Paucis Verbis: Approach to increased osmolal gap
We often talk about calculating the anion gap in the evaluation of patients. What about the osmolal gap? When do you calculate this? What's the differential diagnosis for an increased gap? I recently came upon a nice 2011 review in the American Journal of Kidney Disease called "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". It's always nice to revisit and review this concept. You'll always learn something new. For instance, I didn't know that salicylates cause anion gaps as well as osmolal gaps. So don't forget to calculate an osmolal gap [+]
Trick of the Trade: Mark your sites with a Sharpie
Marking the surface anatomy for procedures can significantly increase your chances for success, such as for lumbar punctures and central lines. I can never seem to find surgical skin markers. [+]
Director of Growth, Strategic Alliance [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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