Trick of the Trade: Converting % to mg/mL
Medication error is something that we all fear in Emergency Medicine and do our best to avoid. Here’s a scenario and simple approach for you, provided by Zlatan Coralic, PharmD (Assistant Clinical Professor in the UCSF School of Pharmacy). You are an emergency physician working in an underserved country. You are presented with an asthmatic kid with severe retractions and tight wheezes. Multiple nebulizers and corticosteroids have failed. You want to try some magnesium sulfate before risking intubation in a place with no reliable access to ventilator equipment. You know the dose should be 1 gm IV over 20 minutes. [+]
Trick of the Trade: Removing a Tungsten Ring Stuck on Your Finger
A patient presents with a tungsten ring on their injured finger and is unable to remove the ring. Tungsten rings are unique in that ring cutters can’t even make a scratch in them. There are even anecdotes of firefighter equipment not being able to cut off these “unbreakable” rings. [+]
Trick of the Trade: Unblocking the obstructed IV line
A patient’s PICC line becomes obstructed and presents to your ED for care. She is using it for chronic antibiotics for osteomyelitis. You are unable to aspirate and flush it with saline using a 10 cc syringe. [+]
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 [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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