Supraventricular Tachycardia (SVT): Are Troponins Necessary?

By |Categories: Cardiovascular|

More than one third of patients will have chest pain associated with SVT causing providers to order troponins and other cardiac enzymes. Elevated troponins are not pathognomonic for CAD/ACS and could represent other etiologies such as sepsis, subarachnoid hemorrhage, and pulmonary embolism. Also, subsequent coronary angiography is not necessary for risk stratification in all cases. SVT causes a rapid heart rate, which is well documented as a cause for modest troponin elevation secondary to cardiac stretch, poor diastolic perfusion, and/or coronary artery vasospasm. […]

Patwari Academy videos: Spider and Hymenoptera bites

By |Categories: Environmental, Patwari Videos|Tags: |

These two videos continue on the theme of envenomations. Watch these great videos on the consequences and management of bites by spiders and Hymenoptera species (bees, wasps, ants). Hymenoptera bites can cause all sorts of complications, but one of the most worrisome includes anaphylaxis, which is also reviewed in the video. […]

Pediatric febrile seizure: When do I need to do a lumbar puncture?

By |Categories: Neurology, Pediatrics|

You are in the ED when a 7 month old is brought in by EMS after a witnessed generalized seizure. The grandmother reports that the child has had URI symptoms for a couple of days and then developed a fever today. Shortly after giving ibuprofen, the child began to seize with arms and legs twitching. The episode lasted approximately 8 minutes and when EMS arrived, the child was sleepy, but arousable. The glucose was 92 mg/dL en route. On exam in the ED, child is awake and staring at you to make the next move… Vitals: Temp 39C, P 136, [...]

Posterior Myocardial Infarction: How Accurate is the Flipped ECG Trick?

By |Categories: Cardiovascular, ECG|

Posterior myocardial infarction (MI) represents 3.3 – 21% of all acute MIs and can be difficult to diagnose by the standard precordial leads. Typically, leads V7 – V9 are needed to diagnose this entity. Luckily, leads V1 – V3, directly face the posterior wall of the left ventricle and are the “mirror image” of the posterior wall of the left ventricle. […]

Safe dosing of nebulized lidocaine

By |Categories: ENT, Tox & Medications|

Serum lidocaine levels correlate well with observed clinical effects. As the concentration increases, lightheadedness, tremors, hallucinations, seizures, and cardiac arrest can occur. Levels > 5 mcg/mL are associated with serious toxicity. With so many concentrations (1%, 2%, 4%) and routes of administration available, the total dose of lidocaine is always a concern. […]

Trick of the Trade: The PIPP for deep peripheral IVs in obese patients

By |Categories: Tricks of the Trade, Ultrasound|Tags: |

The Case A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with a rate of 160 bpm. His BP is in the 130s systolic, and he is otherwise stable. You know you have a bit of time. Meanwhile, the nurses begin searching for veins to start an IV…  […]

Patwari Academy videos: Snake bites!

By |Categories: Patwari Videos|Tags: |

There are about 8,000 snakebites per year in the United States and 10% are fatal (see comments)! If this doesn’t scare you enough to view these videos, watch these videos to see Dr. Rahul’s Patwari’s amazing digital drawing skills. In addition to a brief 4-minute overview on snake bites, Rahul also goes more in depth about crotalids (rattlesnakes) and elapids (coral snakes) specifically. […]

A time-based approach to elderly patients with altered mental status

By |Categories: Expert Peer Reviewed (Clinical), Geriatrics, Neurology|

It’s 7 am on a Monday. Your first patient is an 82 year-old woman who was brought in by EMS from an assisted living facility. All EMS can tell you is that she was not acting herself. You enter her room and introduce yourself. “Hello Mrs. Jones. How are you today?” The woman startles, “Well, you see, I went to put my dog out, and then I was just walking, and couldn’t remember. So it’s all coming full circle, and then I ate a sandwich.” Just then EMS rolls in with another patient, a 75 year-old male coming from home, [...]

PV Card: Intimate partner violence

By |Categories: ALiEM Cards, Trauma|

In the Emergency Department, we too often under-estimate our patients’ likelihood for intimate partner violence (IPV). Unfortunately, there is no perfect screening test to detect this. So one must maintain a high index of suspicion. Once you detect it, what questions should you ask to ensure her/his safety and how do you optimize the resources available to her/him? […]

Alarms from the ventilator: Troubleshooting high peak pressures

By |Categories: Critical Care/ Resus, Expert Peer Reviewed (Clinical)|

Airway management is one of the defining skills of an emergency physician, but our role in the care of intubated patients may continue long after endotracheal tube placement is confirmed. In mechanically ventilated patients, acute elevations in airways pressures can be triggered by both benign and life-threatening causes. When the ventilator alarms, do you know how to tell the difference? What is your approach in troubleshooting the potential problems? […]