• Legionella Infection

Paucis Verbis: Legionella pneumonia

By |Categories: ALiEM Cards, Pulmonary|

Did you know that there was an unexplained spike in Legionnaire’s disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic? Since the flu season is rapidly approaching, I thought I would review what Legionnaire’s disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip. […]

  • Cervical Collar EMS

Paucis Verbis: Distracting injuries in c-spine injuries

By |Categories: ALiEM Cards, Orthopedic, Trauma|

“Distracting injury” is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of “distracting injury”. Although both are studies at different sites, both conclude the same: Chest injuries may be considered “distracting injuries” because of their proximity to the cervical spine. […]

  • BPPV Epley maneuver inner ear

Trick of the Trade: Epley maneuver

By |Categories: Neurology, Tricks of the Trade|

You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous. Is your first-line treatment meclizine or benzodiazepines? […]

  • Dix Hallpike Pillow

Trick of the Trade: Dix-Hallpike maneuver variation

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

The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV). Place the gurney's head of the bed down flat. Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney. Rotate patient's head 45 degrees. Help the patient lie down backwards quickly. The patient's head should be hanging off of the gurney edge in about 20 degrees extension. Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV. I find 2 things challenging in this maneuver. The patient often does not like to be [...]

  • Poison Oak

Paucis Verbis: Approach to rashes

By |Categories: ALiEM Cards, Dermatology|

Doc, what’s this itchy rash? Answer: Contact dermatitis from poison ivy We see a variety of rashes in the Emergency Department. The first step is to accurately describe the rash. Is this a macule or nodule? Is this a vesicle or bulla? The next step is to quickly “profile” the rash to see if it fits any classic pattern by patient age, rash distribution, or presence of hypotension. And finally, if you are still stumped, use an algorithm based on the rash type. […]

  • Sciatica

Trick of the Trade: Crossed straight leg raise test

By |Categories: Orthopedic, Tricks of the Trade|

A 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica? Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is [...]

  • Sinus Tachycardia

Paucis Verbis: An approach to persistent tachycardia

By |Categories: ALiEM Cards, Cardiovascular|

Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can’t send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia? […]