High Sensitivity Troponin Testing

By |Categories: Cardiovascular|

Troponin testing is an important component of the diagnostic workup and management of acute coronary syndromes (ACS). The increasing sensitivity of troponin assays has lowered the number of potentially missed ACS diagnoses, but this has also created a diagnostic challenge due to a decrease in the specificity of the test. From 1995 to 2007, the limit of troponin detection fell from 0.5 ng/mL to 0.006 ng/mL (see below graph). Robert Jesse summed up this frustration with the following quote: When troponin was a lousy assay it was a great test, but now that it’s becoming a great assay, it’s getting [...]

Are Acetaminophen Levels Necessary in All Overdose Patients?

By |Categories: Expert Peer Reviewed (Clinical), Tox & Medications|

Intentional overdose patients are notorious for giving inaccurate histories. “I took 14 tablets of this and 8 capsules of that. No, wait. It was 3 tablets of this and a handful of capsules of that… This happened about 2 hours ago. Actually, I think it was last night.” Round and round the merry-go-round we go. How should we risk-assess whether acetaminophen is involved?  If the patient provides no history of acetaminophen ingestion, do we need to order a level? […]

Introducing Open, Post-Publication, Expert Peer Review on ALiEM

By |Categories: Expert Peer Reviewed (Clinical), Social Media & Tech|

Today, we are busting open the concept of peer review for publications on blogs! The peer review process has been criticized for its flaws, but is universally accepted as a necessary part of the scientific process. Peer reviewing allows experts in a field to determine the validity of a study or an article so that those of us who are less expert can reap the benefits of their knowledge. Until recently this process was almost universally pre-publication and anonymous.  Authors would go through months of review and revision based on feedback of experts whose name they didn’t even know. In the [...]

Alcohol Problems Among Older Adults in the ED

By |Categories: Geriatrics, Tox & Medications|

The complications of alcohol use can be subtle in older adults, and the effects of alcohol are often incorrectly attributed to aging. Because of its under-recognition, the barriers to screening, and the many subtle ways in which it can present, some have suggested that alcohol misuse has replaced syphilis as the “great masquerader”. If you don’t think alcohol misuse is a problem among older adults in your ED, it may be because it has been hidden in plain sight. […]

Simulation Trick of the Trade: Blindfold the Leader

By |Categories: Medical Education, Simulation, Tricks of the Trade|

Simulations are routine now in medical training. But sometimes routine can start to get boring! All learners now know, especially for high fidelity simulations, to prepare for the unexpected. The stable patient will inevitably crash, maybe when your back is turned; the confederate in the room may or may not be a friend or a foe, you may never know! But these twists have become so integral to the simulation case that most learners know how to deal with it, or at the least know to anticipate it. But here is an idea for adding a new challenge to a stale simulation case. Blindfold the leader! […]

Bundle Branch Blocks (BBBs) 101

By |Categories: Cardiovascular, ECG, Expert Peer Reviewed (Clinical)|

Recently, I have been asked by several students at my home institution (UTHSC at San Antonio) to help them understand bundle branch blocks.  This is different than some of my usual posts because it is meant to be more educational than evidence based.  So here we go.  The normal conduction system of the healthy heart is shown to the right.  If there is a delay or block in the left or right bundle, depolarization will take longer to occur. Therefore we get a widened QRS (>0.12 sec or >3 small boxes). […]

R-Wave Peak Time (RWPT) in Lead II: One Simple Step to Differentiate Wide Complex Tachycardias

By |Categories: Cardiovascular, ECG|

There are several algorithms that are currently used to help distinguish Supraventricular Tachycardia (SVT) with aberrancy and Ventricular Tachycardia (VT). Many of these algorithms lack specificity, and let’s face it, who can remember if the absence of an RS complex in the precordial leads is VT or SVT with aberrancy. So what if there was a criterion that had a good sensitivity (SN), specificity (SP), and was one simple step? […]

PV Card: Brugada Criteria for SVT with Aberrancy vs Ventricular Tachycardia

By |Categories: ALiEM Cards, Cardiovascular, ECG, Expert Peer Reviewed (Clinical)|

Due to the overwhelming popularity of Dr. Salim Rezaie’s recent post discussing the Brugada criteria for  SVT with aberrancy vs VT, Dr. Jason West (@JWestEM, an EM resident from Jacobi/Montefiore) kindly helped to co-author and package this information into a PV card for quick reference. To use this sequential, four-question approach, if at any time you answer YES to the question, it is ventricular tachycardia. […]

QI Series: Cellulitis vs Necrotizing Fasciitis

By |Categories: Infectious Disease|

Case A 50-year-old male was referred to the ED for evaluation of cellulitis. The patient had developed pain and swelling in his right groin region 5 days earlier. He had seen his physician 3 days before the ED visit and was started on Doxycycline. On the day of evaluation, he had returned to the office with increasing redness so was referred to the ED. […]

New Quality Improvement Series: Be a detective to avoid errors

By |Categories: Emergency Medicine|

When you attend Morbidity & Mortality or Quality Improvement (QI) Conferences, the cases presented often have teaching points, which revolve around potentially avoidable errors. Subtle and not-too-subtle clues often reveal themselves along the way, which could have been detected sooner. This ALiEM QI Series, hosted by Dr. Steven Polevoi (UCSF EM Medical and QI Director), was created to help you become a better detective in finding these clues early in the patient’s course. “Learn from the mistakes of others. You can’t live long enough to make them all yourself.” – Eleanor Roosevelt […]