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? […]

Critical Care Series by new ALiEM writer Dr. Todd Seigel

By |Categories: Critical Care/ Resus|

Welcome a new superstar blogger, Dr. Todd Seigel (@ToddSeigelMD), to the ever-growing ALiEM team. I first met Todd at the recent Society of Academic Emergency Medicine meeting. At that time, he was an already established clinician-scholar-educator at Brown University. He had already graduated from residency and was returning to fellowship training to get his board-certification in Critical Care Medicine. I’m thrilled that he is now at my home institution (UCSF) doing this fellowship, where I couldn’t resist recruiting him to join our all-star cast of blog authors. Today is the first of hopefully a long series of critical care/resuscitation topics that are [...]

Quick clinical tip: Elson’s test for the finger

By |Categories: Orthopedic|Tags: |

Injuries to the hand are fraught with multiple, concurrent injuries. Many injuries may have chronic debilitating complications, if not detected early. One such example is a finger laceration with a concurrent extensor tendon injury, causing delayed boutonniere deformity formation and limited function. Review the anatomy of the extensor tendon. View the video on how to perform the Elson’s test to detect a central slip tendon injury. […]

Acute Coronary Syndrome (ACS) in the Elderly

By |Categories: Cardiovascular, Geriatrics|

Acute coronary syndrome (ACS) is the number one cause of mortality in patients older than 65 years old. 1 To complicate this fact further, they also present atypically with weakness, nausea/vomiting, fatigue, and shortness of breath.  It has been shown that older adults who present to the emergency department (ED) with ACS and a chief complaint other than chest pain have worse outcomes: […]

Quick clinical tip: Ulnar collateral ligament injury

By |Categories: Orthopedic|

A common thumb injury is the “gamekeeper’s thumb or “skier’s thumb”, which involves an injury to the ulnar collateral ligament (UCL) of the first MCP joint. It is caused by forced abduction and hyperextension of the thumb, such as from a ski pole. But did you know that there are two branches of the ligament that you should test? […]

Supraventricular Tachycardia (SVT) With Aberrancy Versus Ventricular Tachycardia (VT)

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

Differentiating between SVT with aberrancy and VT can be very difficult. It is crucial to be able to make this distinction as therapeutic decisions are anchored to this differentiation. Brugada et al prospectively analyzed 384 patients with VT and 170 patients with SVT with aberrant conduction to see if it was possible to come up with a simple criteria to help differentiate between the two with high sensitivity and specificity. […]

Patwari Academy: ECG Rate, Rhythm, Axis

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

Dr. Rahul Patwari reviews the basics on how to determine an ECG’s rate, rhythm, and axis. It’s always nice to review these concepts. Do you remember how many seconds a traditional ECG typically spans on a single page? What’s the significance of the numbers: 300, 150, 100, 75, 60, 50? Spend a few minutes on these 2 refresher videos. […]

EKG Subtlety: Tall T-Wave in Lead V1

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

EKGs are a simple, cheap modality that can give an emergency physician quite a bit of information.  Sometimes, in a busy ER, this information can be very subtle and almost overlooked without a second thought. A perfect example of this is a New Tall T-wave in  lead V1 (NTTV1). This finding can be a normal variant, but can also be a precursor to badness. […]

Trick of the Trade: Less traumatic nasopharyngoscopy

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

A fiberoptic nasopharyngoscope is a handy tool to check patients for suspected foreign bodies (e.g. fishbone stuck in throat) or laryngeal edema. Depending on the diameter of your fiberoptic cable, it may be fairly uncomfortable for the patient despite generous viscous lidocaine instillation through the nares and nebulized lidocaine. Alternatively or additionally, you can make your own lidocaine-oxymetazoline nasal atomizer which works well.   What if the patient is STILL not tolerating the procedure well?  […]