PEM POCUS Series: Confirmation of Endotracheal Tube Placement

By |Categories: ALiEMU, Pediatrics, PEM POCUS, Radiology, Ultrasound|

Read this tutorial on the use of point of care ultrasonography (POCUS) for confirmation of endotracheal tube (ETT) placement in pediatric patients. 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 ETT Confirmation Quiz Module Goals List indications for performing airway/lung POCUS to confirm ETT placement Describe the technique of performing airway and focused lung POCUS Distinguish between normal and abnormal airway and lung POCUS findings Distinguish between tracheal, endobronchial, and esophageal placement of ETT List [+]

Interpretation and Limitations of Opiate Urine Drug Tests

By |Categories: EM Pharmacy Pearls, Tox & Medications|

Background Urine drug tests are commonly sent for patients in the emergency department, however care should be taken when interpreting the results of these tests given their limitations. The American College of Medical Toxicology published a position statement on the interpretation of urine opiate and opioid tests [1]. In this publication, they outline many of the limitations of opioid urine drug tests and explain why they exist. Evidence Though often used interchangeably, the terms opiate and opioid are not the same. ‘Opioid’ is the broad category name while ‘opiate’ simply refers to the naturally occurring opioids. The term ‘opioid’ encompasses [+]

Should Diphenhydramine be included in an Acute Agitation Regimen?

By |Categories: EM Pharmacy Pearls, Psychiatry, Tox & Medications|

Background Acute agitation in the emergency department is a common issue that frequently requires the use of chemical sedation to preserve safety for patients and healthcare workers. A commonly employed treatment regimen is the combination of haloperidol 5 mg + lorazepam 2 mg + diphenhydramine 50 mg (B-52). Diphenhydramine is included in this treatment regimen primarily to prevent extrapyramidal symptoms [1,2]. However, the incidence of extrapyramidal symptoms (EPS) with haloperidol is quite low when treating agitation in the emergency department (ED) [3,4]. Therefore, the excessive and prolonged sedation from adding prophylactic diphenhydramine may outweigh the intended benefit and should be [+]

PEM POCUS Series: Pediatric Ultrasound-Guided Fascia Iliaca Block

By |Categories: Orthopedic, Pediatrics, PEM POCUS, Ultrasound|

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric fascia iliac block. 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 Fascia Iliac Block Quiz Module Goals List indications of performing a pediatric point-of-care ultrasound fascia iliaca nerve block (POCUS-FINB) List the limitations of POCUS-FINB Describe the technique for performing POCUS fascia iliaca nerve block  Identify anatomical landmarks accurately on POCUS Calculate the maximum safe weight-based local anesthetic dose Recognize the [+]

Are Thrombolytics Safe for Acute Ischemic Strokes in Patients on DOACs?

By |Categories: EM Pharmacy Pearls, Heme-Oncology, Neurology, Tox & Medications, Uncategorized|

Background Direct-acting oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban, and dabigatran, are widely used for various indications and considered first-line therapy for prevention of acute ischemic stroke in patients with nonvalvular atrial fibrillation [1]. The management of acute ischemic stroke in patients on DOACs presents a difficult clinical scenario in the emergency department due to concern for increased risk of hemorrhage. IV thrombolytics (e.g., alteplase, tenecteplase), a mainstay in acute ischemic stroke management, are not recommended in current guidelines for patients whose last DOAC dose was within the last 48 hours [2, 3]. Therefore, patients with an acute ischemic stroke [+]

SplintER Series: Do You Even Lift?

By |Categories: Expert Peer Reviewed (Clinical), Orthopedic, SplintER|

  A 35-year-old male presents after injuring his left shoulder while weight lifting two days ago. He describes sudden-onset pain with associated “pop” in his left anterior/medial shoulder and chest as he was bench pressing. On exam, he has ecchymosis over the medial aspect of his humeral shaft and left chest. He has decreased strength with resisted internal rotation of the shoulder. An MRI is obtained and shown above (Image 1: Case courtesy of Dr. Tim Luijkx,, rID: 36975)   [+]

Blood Pressure Differences in Patients with Acute Aortic Dissections

By |Categories: Cardiovascular, EM Pharmacy Pearls|

Background An acute aortic dissection (AAD) can be a life-threatening emergency which frequently requires rapid and precise control of the patient’s heart rate and blood pressure. The 2010 guidelines for management of patients with thoracic aortic disease suggest a heart rate goal of <60 bpm and a systolic blood pressure between 100-120 mmHg. In order to achieve this, a rapid-acting beta-blocker (i.e., esmolol) may be used in combination with an IV calcium channel blocker (i.e., nicardipine or clevidipine). These medications need to be monitored closely to avoid overshooting these goals and causing hemodynamic compromise. Ideally, an arterial line would be [+]

Dear emergency physicians: We see you

By |Categories: Academic, Emergency Medicine, Life, Medical Education|Tags: | The COVID-19 pandemic has placed incredible stress and strain on the personal work lives of emergency physicians. We have endured these almost 2 years of misinformation, PPE shortages, fear, frustration, grief, and death. So much going on in the world politically and socioeconomically, we at ALiEM wanted to share a message that WE SEE YOU. We're with you, and we're in this together. Credits Thank you for the tireless work on this video by animator Spencer Evans, who is a soon-to-be-emergency physician attending medical school currently at the University of Colorado. Also thanks to the entire ALiEM team for [+]

SAEM Clinical Image Series: Snowball Effects

By |Categories: HEENT, Ophthalmology, SAEM Clinical Images, Trauma|

A 13-year-old boy presented to the emergency department with complaints of a right eye injury. Five hours prior to arrival, he was struck directly in the right eye with a snowball resulting in immediate eye pain, localized swelling, some flashes of light in his vision and blurry vision. Prior to arrival, the patient had been seen at an optometry center where puff pressures of his eyes were obtained and the right eye was noted to have an increased intraocular pressure (IOP) of 46 mmHg compared to a pressure of 13 mmHg on the left. He continued to endorse photophobia [+]