Paucis Verbis: Continuous Infusions
I have always been envious of the residents who carry around the Continuous Infusions cheat-sheet card, which was created by the UCSF Critical Care Units as part of a campaign for Safe Medication Prescriptions. I want one! So I finally managed to wrangle one away for a few minutes and xerox copy it. Here is the abbreviated card, after paring down the list to just ED-focused medications. PV Card: Continuous Infusions Go to ALiEM (PV) Cards for more resources.
Trick of the Trade: Another magnet trick for metallic FB removal
Last week, I talked about the use of Rare Earth Magnets for removing metallic foreign bodies. Sometimes a straight magnet though isn’t quite strong enough to grab a metallic foreign body. If only you had a small magnetic hemostat. This week Dr. Catherine Perry (Culpepper Memorial Hospital) and Dr. Kolapo DaSilva (PGY-2 at UVA) emailed me with a creative solution. They encountered a patient with a BB pellet lodged deeply in the soft tissue. Small mosquito clamps couldn’t get around the BB. A cardiac magnet alone caused the BB to tent the skin up. [+]
Trick of the Trade: Rare earth magnets for metallic FB removal
A child presents to your Emergency Department with a small button battery up her nose. Your usual tricks fail: Occluding the other nostril and having the mother blow in the patient’s mouth forcefully. Using a small curette or forceps to scoop or pull it out. [+]
Paucis Verbis: Anaphylaxis
Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical. A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of "rebound" or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn't a good answer for this. What's your practice in [+]
Paucis Verbis: Pediatric fever without a source (3 mo-3 yr)
In part 3 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants 3 months to 3 years old (PV cards for birth-28 days and 29 days-3 months old). Notes: The algorithm below is a guideline for NON-toxic patients. More ill-appearing children require a more broad workup. For the under-immunized (<2 PCV immunizations) and temperature ≥39.5C, blood cultures may be falling out of favor in the near future, because the incidence of blood culture contaminants is close to exceeding the true incidence of occult bacteremia. PV Card: Pediatric Fever Without a Source (3 Months-3 Years) Go [+]
Paucis Verbis: Fever without a source (29 days-3 months old)
In part 2 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that "high risk" infants get admitted with IV ceftriaxone and "low risk" infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the [+]
Trick of the Trade: Difficult intubation — making lemonade out of lemons
In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in. Unfortunately, when you bag the patient, you realize that you are in the esophagus. [+]
Paucis Verbis: Pediatric fever without a source (Birth-28 days)
Pediatric patients commonly are brought to the Emergency Department for a fever without a source. Management of these patients depends on the patient's age. Today's PV card focuses on the youngest age group: Birth-to-28 days. QUESTION to everyone: Do you correct your age calculation for prematurity? Premature neonates are more at risk for SBI, but I've seen varying practices. PV Card: Pediatric Fever Without a Source (Birth-28 Days Old) Go to ALiEM (PV) Cards for more resources. Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 29 days-3 months and 3 [+]
Trick of the Trade: Minimizing propofol injection pain
“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz… As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection? [+]
Paucis Verbis: Antibiotics and open fractures
Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED. Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides? Pearl Once you have significant soft tissue injury, you are automatically have a Type III fracture and should add an aminoglycoside. PV Card: Open Fractures and Antibiotics Adapted from [1] Go to ALiEM (PV) Cards for more [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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