SplintER Series: One Big Bounce
A 5-year-old boy presents with right leg pain and a limp. His parents report it started after he was bouncing on the trampoline with his older sibling but they did not notice any specific trauma. He has tenderness over his proximal shin with no obvious injury. You suspect a fracture and obtain x-rays of the right knee (Figure 1). Figure 1. AP and Lateral x-rays of the right knee. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 16139 [+]
Beta-Blockers for Inhalant-Induced Ventricular Dysrhythmias
Background There are a few unique scenarios when beta-blockers may be indicated for patients in cardiac arrest. Use of esmolol for refractory ventricular fibrillation was summarized in a 2016 PharmERToxGuy post with an accompanying infographic. Another potential use for beta-blockers is in the rare case of a patient with inhalant-induced ventricular dysrhythmias. The term ‘sudden sniffing death’ refers to acute cardiotoxicity associated with inhaling hydrocarbons. Check out this ACMT Toxicology Visual Pearl for more information about the background and diagnosis of inhalant abuse. It is thought that inhalants causes myocardial sensitization via changes in various cardiac channels (e.g., sodium channels, [+]
SplintER Series: To Immobilize or Not to Immobilize: That is the Question
A patient presents to the Emergency Department after sustaining a twisting knee injury while skiing. She felt a pop and was unable to bear weight afterward secondary to pain and a feeling of instability. Shortly after the injury, she noted increased swelling and pain. On examination, she has a moderate effusion and a positive Lachman test. An x-ray was obtained and is shown above (Image 1. Case courtesy of Mikael Häggström, M.D. – Author info – Reusing images, CC0, via Wikimedia Commons). [+]
PEM POCUS Series: Pediatric Ocular Ultrasound for Optic Nerve Evaluation
Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric ocular ultrasonography for optic nerve evaluation. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit. Take the ALiEMU PEM POCUS: Pediatric Ocular Ultrasound Quiz - test your skills PATIENT CASE: Child with a Headache Madeline is a 15-year-old female presenting to the Emergency Department with chief complaint of a headache for 1 week. She has been struggling with headaches for more than a year. The headache has been intermittent and tends to [+]
SplintER Series: Attack by Bat
30-year-old male presents to the ED with pain over the right shoulder after being assaulted by a bat. The right arm is held in adduction and has a limited range of motion due to pain. An x-ray of the right shoulder was obtained and is shown above (Figure 1. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640). [+]
SplintER Series: The Tooth of the Cervical Spine
80-year-old male patient brought in by ambulance for a witnessed fall. A cervical collar was placed by EMS because of midline neck pain. The patient is neurologically intact. A CT of the cervical spine was obtained and is shown above (Case courtesy of Dr. Talal F M Abdullah, Radiopaedia.org, rID: 58030). [+]
BuMin Kong, MD
Diagnosis on Sight: Neck Bruising Leads to a Surprise Diagnosis
A 76-year-old female with a history of HTN, TIA, CAD, left CEA, and CKD presented to the emergency department for evaluation of neck bruising and swelling. The patient stated that the night before, she was eating popcorn and choked on a kernel. She states that she coughed to clear her throat and shortly after she developed swelling and bruising to the left side of her neck, which has progressively gotten worse. The patient has a remote history of left carotid endarterectomy and was concerned that her symptoms could be related to the prior surgery. On examination, she had ecchymosis and [+]
Trick of the Trade: Upsize the IV with the tourniquet infusion technique
There you are, middle of the night and EMS just brought you one of the sickest of the sick: a septic-looking, chronically ill-appearing, frail, and malnourished patient with low blood pressures. They need vascular access for fluids, antibiotics, and possibly even vasopressors. The patient arrives with only a 22-gauge peripheral IV in the hand. You ask for two large bore IVs. But unfortunately, your best nurses and techs can’t find a vein, and their initial attempts are unsuccessful. Do you move right towards ultrasound-guided placement, intraosseous needle, or a central line? What if the patient only needs a fluid bolus, [+]
Utility of Nebulized Naloxone
Background Naloxone can be administered via multiple routes, with nebulization gaining popularity in the past decade. A previous ALiEM Trick of the Trade presented this unique method of administration. In order for nebulized naloxone to be effective patients need to have some level of respiratory effort. It should not be used in patients in respiratory arrest or impending respiratory arrest. It may be a more gentle way to wake up patients to confirm the diagnosis of opioid toxicity and to gather a history. Theoretically, if the patient arouses enough to start experiencing mild withdrawal, they can ‘self-titrate’ and remove the [+]
SplintER Series: Open Fracture
A 65-year-old farmer presents to the ED after his ankle was run over by a piece of farm equipment in the field. His x-ray is shown above (Figure 1: Case courtesy of Dr. Oyedepo Victor Olufemi, radiopaedia.org) He also has an associated soft tissue injury overlying the area that is grossly contaminated with mud and manure. [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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