Trick of the Trade: EMLA for Lumbar Punctures

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

A 9 year-old patient presents with a headache and fever after swimming, along with subjective neck stiffness. Meningitis was of concern especially because the serum WBC count was 25,000 and other inflammatory markers were elevated. Because the patient’s mother had an unpleasant experience with an epidural during childbirth, she adamantly opposed the idea of a lumbar puncture (LP).  […]

Patwari Academy videos: LVADs

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

Complications from left ventricular assist devices (LVAD) increasingly account for Emergency Department visits. What are LVADs? They are a short-term, artificial, circulatory device which performs the function of a very poorly functioning heart. It is important to understand the myriad of complications that can arise and the general approach to patients with an LVAD. These two short videos by Dr. Rahul Patwari summarize these in a nutshell. […]

Simulation Trick of the Trade: Paper Mache

By |Categories: Simulation, Tricks of the Trade|

Money doesn’t grow on trees, and neither do simulation manikins, not even on simulated trees. So what to do when you are looking for a cheaper, more easily replicated solution to simulation dilemmas? This is the perfect time to fall back on skills developed in childhood during Arts & Crafts hour. Consider paper mache!  So easy to use, and guaranteed to bring back childhood memories! […]

Quick clinical tip: Rotational angulation of metacarpal fracture

By |Categories: Orthopedic|

Metacarpal fractures are commonly present to the Emergency Department for care. The plain film shown here shows metacarpal neck fractures of the middle and ring finger shown. There are specific criteria requiring closed reduction in the ED (PV Card). Generally ANY rotational angulation requires reduction. Detection of such angulation depends on the clinical exam rather than the plain film. How does one diagnose it? […]

Deciphering Acid-Base Disorders

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

Derangements in acid-base status are commonly discovered on routine emergency department evaluation and often suggest the presence of severe underlying disease. Many acute conditions can disrupt homeostatic mechanisms used to buffer and excrete acid, and these changes may necessitate immediate intervention. When you discover a patient with an abnormal pH, what is your approach to the diagnosis? […]

Door to Balloon Time: Are We Measuring the Right Thing?

By |Categories: Cardiovascular|

Door-to Balloon (D2B) time is a time measurement that starts with patient arrival to the emergency department (door) and ends when a catheter crosses a culprit lesion in the cardiac cath lab (balloon). The benefit of prompt primary percutaneous coronary intervention over thrombolytic therapy for acute ST elevation myocardial infarction is very well established. Because of this “time is muscle” strategy, the American College of Cardiology (ACC) launched a national Door to Balloon (D2B) initiative in November 2006. The purpose of this was to recommend a D2B time of no more than 90 minutes. Currently, there is quite a bit [...]

PV Card: Emergency Drug Cards for Adults and Children

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

Rob Bryant, MD (@RobJBryant13), Amie Hatch, PharmD, BCPS (@Amie_EMPharmD), and Jeremy Bair, PharmD (@bairpharm) from Intermountain Healthcare in Utah have created and adopted a fantastic medication reference card which is used by physicians and nurses in the Emergency Department. The medications were chosen because they are often prone to dosing errors and require time-sensitive ordering. They generously offered to share this incredibly compact resource for free to the Emergency Medicine community as a PV card. If you see them, give them a high-five. […]

Patwari Academy videos: PALS

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

Pediatric Advanced Life Support (PALS) guidelines were most recently reviewed in Circulation 2010 1 based on the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science which includes treatment recommendations. Dr. Rahul Patwari nicely summarizes these findings in this series of 8 videos […]

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? […]