Paucis Verbis card: Workup for first-time seizure
How do you workup adult patients who present with a new-onset seizure and now neurologically back to normal? There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches. For the uncomplicated cases (age less than 40 years, afebrile, no comorbidities, no neurologic deficits), the workup is fairly minimal, which includes: Glucose and electrolytes Urine pregnancy test, [+]
Trick of the Trade: Reducing post-LP headache risk
We often do lumbar puncture in the ED. Patients get warned about the potential of a post LP headache. What is the prevalence of a post-LP headache? The literature reports 15% of ED patients have a post LP headache. [+]
Paucis Verbis card: Suture Materials
Suturing is a common procedure performed in the ED, but we too often forget about the nuances of different suture materials. We get set in our practice patterns. This changed when our ED got the fast-absorbing gut suture for surface wounds, especially for pediatric patients. This makes a return visit for suture removal unnecessary because they quickly become absorbed over time. Increasingly, I have observed plastics surgeons using these for surface wound closure of the face and hands. Has anyone else used absorbable sutures on the skin for wound closure? With this new suture material in my armamentarium, I thought [+]
Tricks of the Trade: Finding the wandering contact lens
Contact lens wearers are familiar with the phenomenon of the wandering lens. What should you do if you can’t visualize the contact lens of a patient, who presents with a “lost contact lens” in the eye? You have the patient look in all directions and you evert the eyelid, but still no contact lens can be found. The patient swears that it’s there because of the painful foreign-body sensation. [+]
Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics
In Wednesday's post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada. We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it's difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don't miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache. In this 5-year multicenter study, the investigators [+]
Paucis Verbis card: Cervical spine imaging rules
There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice. The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients. Sensitivity (%) Specificity (%) NEXUS 99.6 12.6 CCR 99.4 45.1 NEXUS National Emergency X-radiography Utilization Study A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are [+]
Trick of the Trade: Self-Reflection
After a shift, we often review the day’s case with our learners. We sometimes ask them to self-reflect. I often used Demian’s ‘Plus/Delta’ approach and ask ‘What did you like /what would you change?’ This approach works well mostly. But, when the answer is ‘I don’t think I would change anything’, it is hard to target teaching and feedback to the learner’s need. [+]
Paucis Verbis card: Dysphagia
Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician. How do you read the figure? Determine first if patient has oropharyngeal vs esophageal dysphagia. Determine if mechanical (problem is solid foods only) vs neuromuscular (problem with liquids and solids)is more likely. Tip: Medications can cause dysphagia from esophageal mucosal injury or reduced lower [+]
Trick of the Trade: Laryngospasm notch maneuver
What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED? Answer = 0.3% A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it. You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first? [+]
Trick of the Trade: Hemostasis of bleeding finger laceration using a glove
Lacerations of the finger can bleed quite profusely because of digital vascularity. This obscures the provider’s ability to perform a careful exam and can make suturing quite difficult. Simple direct pressure over the laceration often controls the bleeding. What if this doesn’t work? [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
Latest posts by Shuhan He, MD (see all)
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