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 [+]
Trick of the Trade: Dental Avulsion and Subluxation
It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground. She’s crying because of the event but is otherwise unscathed. At this point it’s time to take care of the avulsion. What to do? Trick of the Trade Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix [+]
Paucis Verbis card: Interpretation of intraosseous blood
There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab? In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample [+]
Trick of the Trade: A removable guidewire
An essential skill of any innovative troubleshooter in the Emergency Department is the ability to recognize when one piece of equipment may be used elsewhere. For instance, what’s your go-to approach when looking for a spare guidewire? Let’s say you are trying to salvage an ultrasound-guided basilic vein IV catheterization. Here’s where I go for guidewires: Central line kits Pneumothorax pigtail kits Seldinger-based cricothyrotomy kits [+]
Paucis Verbis: Serotonin syndrome
Background Serotonin syndrome is caused by the excess of serotonin and presents classically as: Altered mental status Autonomic instability Neuromuscular hyperactivity Fortunately, there's a nice algorithm (Hunter's decision rule) which helps you decide whether it is serotonin syndrome or not. I also include a table, which I adapted from a New England Journal of Medicine review article, which helps you to differentiate it from its mimickers, such as anticholinergic syndrome, neuroleptic malignant syndrome, and malignant hyperthermia. PV Card: Serotonin Syndrome Adapted from [1, 2] Go to ALiEM (PV) Cards for more resources. A video to remind you what clonus looks [+]
Trick of the Trade: Hip dislocation Part II
As a followup to the blog on the Captain Morgan technique for hip dislocations, I’d like to throw out another similar technique that also does NOT involve climbing up on the gurney. [+]
Director of Growth, Strategic [+]
Trick of the Trade: Tie-over dressing for scalp lacerations
Scalp lacerations are apparently a hot topic these days. This is the third post now on how to apply a bandage to a scalp laceration. Beanie hat using tubular gauze Hair braid dressing [+]
Director of [+]
Trick of the Trade: Captain Morgan technique for hip dislocation
https://www.youtube.com/watch?v=WXN9RMjyn4M Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient’s bed. [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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