• 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? […]

  • Cerebrovascular Anatomy

Paucis Verbis: Blunt cerebrovascular injuries

By |Categories: ALiEM Cards, Cardiovascular, Radiology, Trauma|

In the setting of blunt trauma, it is easily to overlook a patient’s risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke. Who are at risk for these injuries? What kind of imaging should I order to rule these injuries out? Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA? […]

  • Mini suction

Trick of the Trade: A mini-suction device

By |Categories: Tricks of the Trade|

You are doing a shift in the pediatric ED and you are evaluating a kid with a small bead in her ear. There are a ton different approaches you can use (eg. tissue adhesive glue on a q-tip stick). If the bead is in too deep, blindly trying to adhere the foreign body to the glue is a bit risky. Sometimes applying gentle irrigation might not be enough to wash out the bead. You want to avoid irrigation if you worry about a tympanic membrane rupture. […]