Paucis Verbis: Right and posterior ECG leads
A standard 12-lead ECG can be very telling for patients with chest pain or shortness of breath. A right ventricular (RV) and posterior wall infarct, however, can present very subtly. You can obtain special right-sided (V1R-V6R) and posterior leads (V7-V9), if you are concerned. What are the indications for obtaining right-sided and posterior ECG leads? Go to the ALiEM Cards for more resources. Addendum 3/11/11: Right sided ECG leads (V1R-V6R) are positioned in a mirror image fashion from the standard 12-lead precordial leads. Posterior ECG leads (V7-V9) are applied by moving V4-V6 in the posterior positions.
Trick of the Trade: Heat it up!
What is it about heat that makes everything feel better? Fireplace, hot tub, heat packs, electric blankets, and hot chocolate have got to be the best inventions EVER. How can we apply this in Medicine? [+]
Trick of the Trade: Website resource on HIV medications
At our department’s first annual UCSF High Risk Hawaii Conference 2 weeks ago, Dr. Rachel Chin taught about complications from all of the HIV drugs on the market now. It’s a virtual alphabet soup: EFV, TDF, FTC, oh my. How do you keep track of them all? [+]
Hot off the press: Clinical practice guideline for ketamine in the ED
A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction. Hhhmmmm…how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions! Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was [+]
Paucis Verbis: Pneumonia risk stratification tools
Pneumonia is a common cause for ED visits. How do you decide on whether the patient can be managed as an outpatient or inpatient? To supplement your clinical judgment, many clinicians use the Pneumonia Severity Index (PSI) score. Have you heard of CURB-65, supported by the British Thoracic Society? What about SMART-COP, which is meant to help you predict if your patient will need Intensive Respiratory or Vasopressor Support (IRVS)? PV Card: Risk Stratification Scoring Tools in Pneumonia Go to the ALiEM Cards for more resources.
Paucis Verbis: Assessing patients with suicidality in the ED
Dr. Rob Orman emailed me last week about creating a pocket card on Suicide Risk Stratification. In many community ED's, risk assessment is done by the emergency physician. I'm lucky where I work, because we have a 24/7 psychiatric ED, which consults on suicidal patients in the "medical ED". In the end, assessment is primarily based on physician judgment, because there's no great clinical decision tool, rules, or scores to assess risk. Rob has created his own mnemonic to help you ask the right questions in assessing a suicidal patient. This is a sneak peek into a larger article that [+]
Trick of the Trade: Serial lactate measurements in sepsis?
Does your Emergency Department have computerized spectrophotometric catheters to measure continuous central venous oxygen saturation (ScvO2) in early goal directed therapy (EGDT) for severe sepsis? That’s what was used in the original Rivers’ EGDT study. I’ve never even seen one before. [+]
Trick of the Trade: Conveying risk for postexposure prophylaxis
A health care worker hurried in to the ED after being poked with a needle. ‘It was an old 18G needle with dried blood’, she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, ‘What does very low risk mean?’ Is there another way to covery risk for patients? [+]
Paucis Verbis: Management of Accidental Hypothermia
With all of the amazing, sunny weather here in California, I feel (briefly) terrible for all those braving the snowpocalyptic conditions across the United States. So, in honor of all those bundled up and shivering, I wanted to review the management of accidental hypothermia. Tip: Avoid jostling the hypothermic patient too much because of myocardial irritability. Don't send your patient into an arrhythmia. PV Card: Management of Accidental Hypothermia Go to ALiEM (PV) Cards for more resources.
Trick of the Trade: Getting an EKG on Chewbacca
Patients with a hairy chest may require little patches of hair to be shaved when applying EKG leads. This allows the leads to stick firmly to the chest. Loose leads will result in either an artifactual signal or no signal at all on the EKG machine. How can you obtain an EKG without shaving little patches on the patient’s chest? [+]
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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