• Lactate chemistry

Geriatric Blunt Trauma – Respect the Lactate

By |Categories: Geriatrics, Trauma|

Which is a better prognostic tool in geriatric trauma, traditional vital signs or lactate level? Meet Norma Nuance (NN), a 70-year-old woman with CAD, HTN, HLD, DM, and mild dementia. She was involved in an MVC as the restrained driver with questionable LOC. She arrives in your ED and appears confused, but has a history of dementia. There are no family members to tell you her baseline. Her BP is 120/80, and her HR is 90. She is not calling out in pain, but does mumble about her left arm when you ask if she is hurting. You think she [...]

Welcome new series Geriatric EM by Dr. Christina Shenvi

By |Categories: Geriatrics|

Welcome a new superstar blogger, Dr. Christina Shenvi (@clshenvi), to the ALiEM team. If there’s one talent I have, it’s spotting the rising academic star. As the new Geriatrics EM fellow at the University of North Carolina, she’ll be starting her monthly series of blog posts on Geriatric EM. I jumped at the chance when she came up with the idea of this series, since there is never enough teaching about the unique aspects in the emergent care of older patients. Since meeting her in March 2013 at the annual CORD meeting, it’s been the longest 4 months anxiously waiting [...]

  • platelet aggregation

Patwari Academy videos: Anticoagulation and reversal agents

By |Categories: Heme-Oncology, Patwari Videos, Tox & Medications|Tags: |

Bleeding in general is bad. Bleeding while on anticoagulants is VERY bad. Dr. Rahul Patwari reviews the pathophysiology of coagulation, the various reversal agents, and treatment approaches we can use. In this five-part series where all videos are less than 10 minutes, Rahul goes from the basic physiology of coagulation all the way to the complex reasoning and approaches to reversing anticoagulants. These are worth a quick look and review. […]

  • Peanut Allergy Bracelet

The Dirty Epi Drip: IV Epinephrine When You Need It

By |Categories: Allergy-Immunology, Tox & Medications, Tricks of the Trade|

You’re a recent graduate picking up an extra shift in a small ED somewhere north of here. At 3 AM an obese 47 year-old woman presents with shortness of breath and difficulty speaking after eating a Snickers bar an hour earlier. She admits to history of hypertension, peanut allergy, and a prior intubation for a similar presentation. She is becoming more obtunded in the resuscitation room as you are collecting your history. A glance at the monitor shows: HR 130 BP 68/40 O2 saturation 89% on room air […]

  • Brugada Syndrome

Brugada Syndrome: An ECG Pattern You Need to Know

By |Categories: Cardiovascular, ECG|

Brugada Syndrome is an abnormal ECG (Right Bundle Branch Block Pattern with coved ST elevation over the right precordial leads of V1-V3), which leads to ventricular fibrillation (VF) and sudden cardiac death (SCD) in patients with structurally normal hearts. It has been recognized as a clinical entity since 1992. Why should all ED physicians know about this entity? Although a rare syndrome, it is often mistaken as a STEMI and more importantly the clinical spectrum can be asymptomatic to SCD. […]

Trick of the Trade: Got a shoulder dislocation? Park it

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

Myriad techniques exist to reduce shoulder dislocations, which includes scapular rotation, Hennepin, Snowbird, Cunningham, and Legg maneuvers. They are nicely reviewed at ShoulderDoc.co.uk. You can also supplement any technique with ultrasound-guided intraarticular lidocaine for improved pain control. Recently, Dr. Jay Park (Beth Israel Medical Center in New York) contacted me about his novel approach to shoulder reduction which anatomically makes sense. If his animation video doesn’t convince you, check out the video of an actual reduction. […]

  • Prolonged QTc Magnesium

Patwari Academy video: Torsades de Pointes

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

Torsades de pointes is a polymorphic form of ventricular tachycardia. Why does this occur? What does it characteristically look like? Why is this an important form of ventricular tachycardia to differentiate from the more classic monomorphic ventricular tachycardia? View this short 9 minute video on QT intervals and Torsades de Pointes. […]

  • STE in aVR

Lead aVR: The Forgotten 12th Lead

By |Categories: Cardiovascular, ECG|

Augmented leads (aVR, aVF, and aVL) were developed to derive more localized information looking at the right, lower, and left part of the heart respectively.  Specifically, lead aVR obtains information from the right upper side of the heart.  It also gives reciprocal information on the left lateral side of the heart, which is already covered by leads aVL, I, II, V5, and V6.  This is the main reason lead aVR has become forgotten. […]

  • Radar

Wellens’ Syndrome: Is it on your radar?

By |Categories: Cardiovascular, ECG|

Wellen’s Syndrome was first described in 1982 in which 75% of patients with t wave inversions in V2-V4 went on to have an acute myocardial infarction (MI). This was again repeated in 1989, and showed that all patients with this morphology had >50% LAD stenosis. The incidence in the United States is about 10-15%. […]