Paucis Verbis: Blunt Abdominal Injury, Likelihood Ratios
This month's issue of JAMA addresses the question "Does this patient have a blunt intra-abdominal injury?" as part of the always-popular Rational Clinical Examination series. The systematic review of the literature summarizes the accuracy of findings for your blunt trauma patient in diagnosing intra-abdominal injuries. Specifically, likelihood ratios (LR) are summarized. These LRs can be used to plot on the Bayes nomogram below. You draw a straight line connecting your pretest probability and the LR. This yields your posttest probability. The most predictive positive LR include: Abdominal rebound tenderness, a "seat belt sign", ED hypotension, hematocrit < 30%, AST or [+]
Trick of the Trade: Peritonsillar abscess aspiration technique using IV tubing
A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion. An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter. [+]
Paucis Verbis: GRACE score for ACS risk stratification
Risk stratification of the undifferentiated chest pain patients in the Emergency Department continues to plague emergency physicians. It's partly the reason why I created a TIMI risk score card for unstable angina and non-ST elevation MI in 2010. Have you heard of the 9-variable GRACE risk stratification score? Thanks to Jeff Bray (physician assistant in a rural critical access ED), I have now. He graciously shared his personal reference card on this with me, which I only minimally reformatted to fit my Paucis Verbis card dimensions. GRACE stands for Global Registry for Acute Coronary Events. It supposedly outperforms the TIMI [+]
Trick of the Trade: Urine pregnancy test without urine
A 25 year old woman presents to the Emergency Department having syncopized in the waiting room, where she was triaged with the chief complaint of abdominal pain. Ectopic pregnancy immediately bubbles to the top of your differential diagnosis. The patient is too dizzy to walk to the bathroom to give you a urine specimen to check a urine pregnancy test. Plus, she admits that she just urinated in the waiting room bathroom a few minutes ago - so no urine now. Trick of the Trade Apply several drops of whole blood (instead of urine) into the pregnancy test cassette. In the [+]
Modern EM: Case #4 – Palpitations
Case # 4: Palpitations A 25 year old woman presents with palpitations, sweating, and shortness of breath since this morning. 6 days ago she had syncopized, was shocked out of V-tach by EMS, and eventually had a defibrillator placed for an unknown arrhythmia. Now, she feels her heart beating in her chest, looks diaphoretic, is tachypnic, but her pulse is 58 and regular. [+]
Trick of the Trade: Fluorescein eyedrops
This is a guest post by Dr. Ian Brown (Stanford): The Roberts textbook describes the procedure of corneal fluorescein staining as touching a moistened fluorescein strip to the cornea. Maybe it is an irrational fear of a paper cut to the sclera, or a fear of touching an already abraded cornea with the paper, but I try to find an alternative. I have seen physicians hold the eye open with one hand, hold the fluorescein with a second hand and then drip tetracaine on the paper and let it drip into the eye with a third hand. I, unfortunately, only [+]
Modern EM: Case 1 and 2 – Strep Throat
A sister and brother, aged 7 and 14, respectively present with pharyngitis. The 7F has sore throat, cough, fever, and post-tussive vomiting for 1 day. She has posterior pharyngeal erythema, no lymphadenopathy, no exudate, no petechiae, and looks like a viral URI. The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved. Now, he’s in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, LAD, and petechiae on his hard palate. [+]
Paucis Verbis: Kawasaki Disease
Kawasaki Disease can be easy to diagnose when you have the pediatric patient, who presents with all 5 of the classic clinical findings. What happens when you have the prerequisite fever for ≥5 days, but only 2-3 clinical criteria? What ARE the 5 classic findings? When do you do waitful watching? When do you perform an echo? When do you treat empirically? Check out the nice flowchart below which addresses these questions. They summarize the most recent (2004) American Heart Association's consensus group's recommendations. PV Card: Kawasaki Disease (AHA 2004) Adapted from [1] Go to ALiEM (PV) Cards for more [+]
Trick of the Trade: Pelvic speculum for peritonsillar abscess
Peritonsillar abscess drainage in the ED continues to be one of my favorite procedures to perform. There are several tricks to increase your chances for a successful aspiration. One trick involves using a curved laryngoscope to help depress the tongue AND provide a bright light source. What if you don’t have a laryngoscope readily available? [+]
Trick of the Trade: Irrigation fluid is key – but not in your eye!
High pressure irrigation of wounds is critical in reducing the rate of wound infection. There are a variety of commercial irrigation kits which include splash guards. If you are irrigating correctly and generating at least 8 PSI of pressure, some irrigation fluid should splash up and out of the wound. Be careful not to splash irrigation fluid in your eyes. What if you don’t have a commercial irrigation setup? [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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