• Epi-pen Thigh

Paucis Verbis: Anaphylaxis

By |Categories: ALiEM Cards, Allergy-Immunology|

Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical. A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of “rebound” or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn’t a good answer for this. […]

Paucis Verbis: Fever without a source (29 days-3 months old)

By |Categories: ALiEM Cards, Pediatrics|

In part 2 of this “Pediatric Fever Without a Source” Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that “high risk” infants get admitted with IV ceftriaxone and “low risk” infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the [...]

  • Endotracheal Tubes

Trick of the Trade: Difficult intubation — making lemonade out of lemons

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

 In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in. Unfortunately, when you bag the patient, you realize that you are in the esophagus.   […]

  • Lidocaine Tourniquet

Trick of the Trade: Minimizing propofol injection pain

By |Categories: Tox & Medications, Tricks of the Trade|Tags: |

“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz… As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection? […]

Paucis Verbis: Antibiotics and open fractures

By |Categories: ALiEM Cards, Orthopedic|

Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED. Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides? […]

  • Close up repair dental avulsion

Trick of the Trade: Dental Avulsion and Subluxation

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

It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground.  She’s crying because of the event but is otherwise unscathed.  At this point it’s time to take care of the avulsion.  What to do? (see PV Card on ED Treatment of Dental Trauma) […]

Paucis Verbis card: Interpretation of intraosseous blood

By |Categories: ALiEM Cards, Heme-Oncology|

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab? […]