• Blood transfusion Drip Chamber

Paucis Verbis: Upper GI bleeding

By |Categories: ALiEM Cards, Gastrointestinal|

Do you know what the Blatchford clinical prediction score is for upper GI bleeding? It can help you predict whether a patient with an upper GI bleed is severe and requires urgent intervention. Hot off the presses, JAMA just came out with a great Clinical Rational Examination article on this topic. Thanks to Dr. Ryan Radecki (EMLitOfNote) for the heads up. The likelihood ratios and Blatchford risk stratification score are so useful that I’m breaking my PV rule to keep things down to the size of one index card. Note the absence of a NG lavage result to help you [...]

  • Aspen Collar

Trick of the Trade: Stabilizing mandibular relocations

By |Categories: ENT, Tricks of the Trade|

Three weeks ago, I talked about more safely reducing mandibular dislocations. After successful completion of the procedure, how do you make sure that the patient doesn’t re-dislocate the mandible? You definitely should tell the patient to keep their jaw closed as much as possible for the next 24 hours and avoid opening the mouth widely (eg. yawning/laughing). How do you immobilize the mandible? Especially for the chronic dislocators, presumably with more lax TMJ ligaments, you should think about immobilization. This can be done with a head bandage which goes under the chin. You can use kerlix rolls or an ACE [...]

Paucis Verbis: Genital Ulcers

By |Categories: ALiEM Cards, Genitourinary|

A few months ago, American Family Physician published a nice review article on the diagnosis and management of genital ulcers. How do you remember the classic appearances of the lesions? I often quickly check references to confirm my suspicions. I find the two following tables helpful to remember. The table of differential diagnoses is from AFP. The article also reviews the confirmatory diagnostic testing and treatment protocols. The table of the clinical characteristics for the main infectious causes is from “The Practitioner’s Handbook for the Management of Sexually Transmitted Disease”. […]

  • Hemo pneuomothorax

Trick of the Trade: Seldinger chest tube technique using bougie

By |Categories: Social Media & Tech, Tricks of the Trade|Tags: |

A 40 year-old man presents with a traumatic hemopneumothorax. He weighs 400 pounds. Chest tubes can sometimes be challenge, especially for those with extra redundant tissue to tunnel through before reaching the intrathoracic cavity. You want to avoid placing the chest tube mistakenly in the subcutaneous space. How can you ensure that your chest tube actually reaches the intrathoracic space? […]

  • Mandible relocation

Trick of the Trade: Protecting your thumbs in mandible relocations

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

Does anyone think that this is generally a bad idea when closed-reducing mandible dislocations? Yes, it's easiest to apply downward pressure on the mandible by pushing down on the occlusal surfaces of the molar teeth. Sometimes, however, when the mandible relocates into place, the teeth clamp shut abruptly - placing your thumbs at risk. How can you prevent any injuries to yourself? One way is to slide gauze into the mouth during your procedure. Start the video around the 1:30 mark for an exam.   Trick of the Trade: Mandible Relocations Apply a protective roll of gauze over each thumb. [...]

  • Likelihood ratio example

Paucis Verbis: Blunt Abdominal Injury, Likelihood Ratios

By |Categories: ALiEM Cards, Gastrointestinal, Trauma|

This month’s issue of JAMA addresses the question “Does this patient have a blunt intra-abdominal injury?” as part of the always-popular Rational Clinical Examination series. The systematic review of the literature summarizes the accuracy of findings for your blunt trauma patient in diagnosing intra-abdominal injuries. Specifically, likelihood ratios (LR) are summarized. These LRs can be used to plot on the Bayes nomogram below. You draw a straight line connecting your pretest probability and the LR. This yields your posttest probability. […]

  • Peritonsillar abscess

Trick of the Trade: Peritonsillar abscess aspiration technique

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

A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion. An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter.   I can never find syringes with the side rings to allow you to grasp the syringe more securely with one hand (see photo above). […]