• BPPV Epley maneuver inner ear

Trick of the Trade: Epley maneuver

By |Categories: Neurology, Tricks of the Trade|

You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous. Is your first-line treatment meclizine or benzodiazepines? [+]

Shuhan He, MD

  • Urine Bacteria

Paucis Verbis: Antibiotics for Cystitis and Pyelonephritis in Women

By |Categories: ALiEM Cards, Genitourinary|

You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis? Answer: It depends on your local antibiogram. San Francisco General Hospital 2010 Antibiogram Today, go find out about your hospital's local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin: Trimethoprim-sulfamethoxazole resistance rate = 33% Cefazolin or Cephalexin resistance rate = 12% Ciprofloxacin resistance rate = 16% So based on the [+]

  • Dix Hallpike Pillow

Trick of the Trade: Dix-Hallpike maneuver variation

By |Categories: ENT, Neurology, Tricks of the Trade|

The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV). Place the gurney's head of the bed down flat. Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney. Rotate patient's head 45 degrees. Help the patient lie down backwards quickly. The patient's head should be hanging off of the gurney edge in about 20 degrees extension. Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV. I find 2 things challenging in this maneuver. The patient often does not like to be [+]

  • Poison Oak

Paucis Verbis: Approach to rashes

By |Categories: ALiEM Cards, Dermatology|

Contact dermatitis from poison oak We see a variety of rashes in the Emergency Department. The first step is to accurately describe the rash. Is this a macule or nodule? Is this a vesicle or bulla? The next step is to quickly "profile" it to see if it fits any classic pattern by patient age, lesion distribution, or presence of hypotension. And finally, if you are still stumped, use an algorithm based on the rash type. These figures are from March 2010's Emergency Medicine Magazine. It's not meant to be a comprehensive article on rashes but it sure does [+]

  • Sciatica

Trick of the Trade: Crossed straight leg raise test

By |Categories: Orthopedic, Tricks of the Trade|

A 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica? Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is [+]

  • Sinus Tachycardia

Paucis Verbis: An approach to persistent tachycardia

By |Categories: ALiEM Cards, Cardiovascular|

Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can't send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia? Attached is a list of common causes of tachycardia in the ED, as well as potential diagnostic and therapeutic considerations. Rather than a shot-gun approach, a limited and thoughtful method works best. [+]

  • Ear Splint

Trick of the Trade: Splinting the ear

By |Categories: ENT, Trauma, Tricks of the Trade|

One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space? Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging [+]

  • spinal epidural abscess

Paucis Verbis: Spinal epidural abscess

By |Categories: ALiEM Cards, Infectious Disease, Neurology|

One of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There's never before been a published diagnostic guideline or algorithm which helps you with risk-stratification. In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less [+]

Shuhan He, MD

Shuhan He, MD

ALiEM Senior Systems Engineer;
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
Shuhan He, MD