• Ear Splint

Trick of the Trade: Splinting the ear

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

One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space? Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging [...]

  • spinal epidural abscess

Paucis Verbis: Spinal epidural abscess

By |Categories: ALiEM Cards, Infectious Disease, Neurology|

One of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There’s never before been a published diagnostic guideline or algorithm which helps you with risk-stratification. In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less [...]

  • Pulmonary embolism

Paucis Verbis: Fibrinolytics for PE

By |Categories: ALiEM Cards, Cardiovascular, Pulmonary|

When would you give fibrinolytics for a Pulmonary Embolism? This Paucis Verbis card summarizes recommendations found in Circulation’s recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated. […]

Trick of the Trade: Making a beanie hat

By |Categories: Tricks of the Trade|

Scalp lacerations are a common condition in the Emergency Department. Some require no bandage over once the injury is repaired. Because the scalp is so vascular, others require a pressure dressing over the site to minimize hematoma formation. How do you bandage these patients? It is difficult to secure any wrap or square gauze over the site, because the head is round and the hair is slippery. […]

  • Abd Pain

Paucis Verbis: Diagnostic testing tips for acute abdominal pain

By |Categories: ALiEM Cards, Gastrointestinal, Radiology|

In the most recent EM Clinics of North America publication, Dr. Panebianco et al. discussed the evidence behind diagnostic tests for acute abdominal pain. There were some really great teaching points in this broad-reaching topic. My favorite pearl: A 3-way acute abdominal series is too insensitive to rule-out any major acute causes of abdominal pain with confidence. So stop ordering them routinely. If you are worried about a perforated viscus, order an upright chest x-ray instead — more accurate and less radiation. […]

  • Foreign Body

Tricks of the Trade: Underwater ultrasonography

By |Categories: Tricks of the Trade, Ultrasound|

I've heard of underwater basketweaving, but underwater ultrasonography? Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient's extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient's skin and transducer. What's a quicker and easier way to create some distance yet preserve image quality? Trick of the Trade Submerse [...]

  • NSAIDs

Paucis Verbis: NSAIDS and upper GI bleeds

By |Categories: ALiEM Cards, Gastrointestinal, Tox & Medications|

Primum non nocere. Do no harm. We so often recommend and give NSAIDs to patients for various painful conditions. We also commonly administer ketorolac (toradol) in the ED, because it works so amazingly well for renal colic. When giving various NSAIDs, what is the relative risk (RR) for an upper GI bleed or perforation in the first year? […]

  • Visc Lidocaine

Trick of the Trade: Anesthetizing the nasal tract

By |Categories: ENT, Tricks of the Trade|

  One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness. […]

  • cardiac tamponade

Paucis Verbis: Cardiac tamponade or just an effusion?

By |Categories: ALiEM Cards, Cardiovascular, Ultrasound|

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion. But what we more want to know in the immediate setting is: Is this cardiac tamponade? You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade? […]