Paucis Verbis: Dental trauma
How cool is this -- I have talented emergency physicians contributing Paucis Verbis card content! This week features excellent pearls on Dental Trauma by Dr. Hans Rosenberg (University of Ottawa). Here's his recent article in Annals of EM on reimplantation of avulsed teeth.1 PV Card: Dental Trauma Go to ALiEM (PV) Cards for more resources. Reference Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. [PubMed]
Trick of the Trade: Oblique CXR to look for pneumothorax
Supine chest xrays have an extremely low sensitivity (12-24%) in detecting pneumothoraces. Because a pneumothorax layers anteriorly on an AP CXR film, the xray beam is perpendicular rather than tangential to the pneumothorax edge. This makes visualizing a small to moderate sized pneumothorax extremely difficult. So you are left to look for indirect signs such as a deep sulcus at the costophrenic angle or subcutaneous air. I’m often surprised at how large of a pneumothorax can be missed on CXR based on CT imaging. The image to the right shows a large left-sided pneumothorax on CT. What if you [+]
Paucis Verbis: AMI and ECG Geography
Sometimes a picture is worth MORE than a 1000 words. Such is the case of the above illustration that I saw on the Life In The Fast Lane blog. When I first saw it, I knew that I immediately had to find out who made the graphic. It turns out it is the multitalented Dr. Tor Ercleve, who is an emergency physician at Sir Charles Gairdner Hospital and an established medical illustrator. This graphic demonstrates the EKG findings for the various types of acute MI's as broken down by coronary vascular anatomy (right coronary artery, left circumflex artery, left anterior descending [+]
Trick of the Trade: Check pupillary constriction with ultrasound
In some trauma patients with head and face trauma, you will need to check their pupillary response to light. Severe periorbital and eyelid swelling, however, make this difficult. You want to minimize multiple attempts to retract the eyelids because of the risk of a ruptured globe. What’s a minimally painful and traumatic way to check for pupillary constriction? [+]
Paucis Verbis: Post-exposure prophylaxis (non-occupational)
You know how chief complaints present to the ED in multiples? In one week, I had several cases where patients were asking for post-exposure prophylaxis treatment NOT in the content of a sexual assault. I haven't had to manage such cases in a long time and so needed to look up the recent guidelines from the CDC.1 The trick is not to forget about all the co-existing problems and infections beyond just HIV. Specifically, don't forget about gonorrhea, chlamydia, and trichomonas. PV Card: Post-Exposure Prophylaxis for Non-Occupational Contact Adapted from [2] Go to ALiEM (PV) Cards for more resources. [+]
Trick of the Trade: Steristrip-suture combo for thin skin lacerations
Lacerations of elderly patients or chronic corticosteroid users can be a challenge because they often have very thin skin. Sutures can tear through the fragile skin. Tissue adhesives may not adequately close the typically irregularly-edged laceration. How do you repair these lacerations? Do you just slap a band-aid on it? [+]
Paucis Verbis: Chemical sedation for severe agitation
Haldol, Ativan, and Versed... oh my. In the Emergency Department, some patients present very acutely and aggressively agitated. This is usually the result of illicit drug use or a schizophrenic who hasn't been taking medications (or both!). Fortunately, we have an arsenal of medications to help sedate the patient. One study looked to answer the question of what single IM sedation agent is most effective, as measured by the shortest time to sedation and time to arousal. PV Card: Chemical Sedation for Agitation Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Nobay F, Simon BC, [+]
Trick of the Trade: Benzoin for opening traumatic, swollen eyelids
Patients who sustain facial trauma often have swollen eyelids. They may be so swollen that it is impossible to pull back the eyelids for an ocular exam. You use one of our “Tricks of the Trade”ideas and attempt to “roll” the upper eyelid using the Q-tip trick (above).Fresh blood on the face, however, makes the Q-tip a little slippery along the upper eyelid, preventing an adequate view of the eye itself. [+]
Paucis Verbis: Strength of diagnostic tests for cholecystitis
You have a 40 year-old man who presents to the ED for persistent right upper quadrant abdominal pain for 12 hours after eating a fatty meal. He has no fevers, nausea, flank pain, or dysuria. His physical exam shows no fever and only moderate tenderness in the RUQ without guarding. He has a Murphy's sign which is improved after a total of 8 mg of IV morphine. His laboratory results, which include a WBC, liver function tests, lipase, and urinalysis, are normal. Can you safely say that the patient doesn't have cholecystitis? Can you discharge him for outpatient ultrasonography to [+]
Trick of the Trade: Topical anesthetic cream for cutaneous abscess drainage in children
Abscess drainage can be painful and time consuming in the ED. Can this article help? 1 Trick of the Trade Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D). In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children. [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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