ALiEM presents Trick of the Trade! Dual Foley Catheter for Massive Epistaxis!
You`ve tried all the things including anterior nasal packing soaked in epinephrine and TXA, yet your patient is still having massive epistaxis. Trick of the Trade ➡️ try a dual foley catheter!
Technique:
1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
2. Inflate the balloon partially with 15-20 cc of air.
3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.
For more info and other Tricks of the Trade, click the link in bio! 📲
https://www.aliem.com/trick-dual-foley-catheter-massive-epistaxis/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM Trick of the Trade: Removal of Entrapped Metal Zipper!
Materials Needed:
- Lidocaine gel
- Blade or scissors
Technique:
1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin.
4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
5. The remaining parts of the zipper can easily be disengaged from the skin.
For more info, click link in bio! 📲
https://www.aliem.com/trick-trade-removal-entrapped-metal-zipper/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM is back with EM Match Advice 40: Program Directors Reflect on the 2023 Match
The 2023 Emergency Medicine Match was an unprecedented year that took many of us in the education community by surprise. There were 132 (46%) EM residency programs with at least one unfilled PGY-1 position, and there were 554 (18.4%) overall unfilled EM positions. Dr. Sara Krzyzaniak (EM program director at Stanford) hosts this important episode with Dr. Michelle Lin (ALiEM/UCSF), reflecting on the whys, hows, and what nexts. Fortunately we have experts Dr. Abra Fant (Northwestern PD) and Dr. Richard Church (University of Massachusetts PD) to help us with a deeper dive and forecasting the future.
Checkout the full podcast by clicking the link in bio! 📲
https://www.aliem.com/em-match-advice-40-program-directors-reflect-2023-match/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM is back with another SAEM Clinical Image Series: Incidental Finding on Bedside ECHO
A 48-year-old woman presents with abdominal pain and bilious emesis. An ECHO was performed for bradycardia and a brief episode of hypoxia in the emergency department. A large, tethered mass is seen likely originating from the left atrium. This finding is most consistent with an atrial myxoma, though it can also represent a clot. The patient was ultimately diagnosed with gallstone ileus and an atrial myxoma!
Take-Home Points
💥 Myxomas are the most common type of cardiac mass. They occur more commonly in females, arising between the 4th and 6th decades of life. They are most commonly located in the left atrium.
💥 Patients can experience obstructive and thromboembolic symptoms. Distal embolic events can cause neurologic deficit, visceral ischemia, STEMI, and limb ischemia amongst other critical presentatations.
Click link in bio for more info! 📲
https://www.aliem.com/saem-clinical-images-series-incidental-finding-bedside-echo/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM presents ACMT Toxicology Pearl: Methylene Blue for Refractory Vasoplegic Shock!
Methylene blue is FDA approved for the treatment of methemoglobinemia but has increasingly been used off-label in vasoplegic shock as a potent vasoconstrictor.
How does methylene blue work as a vasopressor?
Mechanisms of Action
💥 Vasopressor: Methylene blue inhibits NO-induced guanylyl cyclase conversion of GTP to cyclic GMP, an intracellular signaling molecule for vasodilation. It also downregulates endothelial NO synthase.
💥 Methemoglobinemia: Methylene blue is an electron shuttle from NADPH in order to reduce Fe3+ in methemoglobin to Fe2+ in hemoglobin.
Click link in bio to learn more! 📲
https://www.aliem.com/acmt-toxicology-visual-pearl-silver-bullet-refractory-vasoplegia-blue/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM is back with SAEM Clinical Image Series!
An 8-year-old boy with no past medical history presented to the ED with 3 days of abdominal pain, dysuria, nausea, vomiting, and poor oral intake. He had microscopic hematuria and massive bilateral hydronephrosis on POCUS. This presentation in a male, together with the lab findings suggestive of a UTI, should raise concerns for posterior urethral valves (PUV)!
💥 PUV, a congenital obstruction of the urethra, is one of the most common causes of lower urinary tract obstruction in males.
💥 While rare, PUV should be considered in the differential for any pediatric patient presenting with urinary tract-related complaints, abdominal pain, and unexplained nausea or vomiting, particularly in school-aged males.
💥 Patients with probable PUV need a referral to a urologist for a voiding cystourethrogram (VCUG) and cystoscopy to assess for vesicoureteral reflux and valvular obstruction. Patients who are found to have PUV can then undergo incision and correction of the urethral valve.
Click link in bio for more info! 📲
https://www.aliem.com/saem-clinical-images-series-8-year-old-male-with-dysuria/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM presents SAEM Clinical Image Series: My Eye Looks Different
A 29-year-old man presents to the ED for blurry vision, redness, and concern for a deformity to his right eye. Symptoms started 2-3 months ago, but over the past 3-4 days he noticed an acute decline in his vision with a “cloudy bump” appearing. He also has photophobia and mild eye pain. What is the suspected diagnosis?
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Corneal hydrops secondary to keratoconus
💥 Suspect keratoconus in patients with a history of constant eye rubbing, developmental delay (i.e. Down Syndrome), and in patients with connective tissue disorders.
💥 Munson’s Sign is a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward.
💥 Initial treatment of keratoconus is conservative management with prompt ophthalmology follow-up.
Click link in bio for more info! 📲
https://www.aliem.com/saem-clinical-images-series-my-eye-looks-different/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM presents SAEM Clinical Image Series: A Rare Pediatric Scalp Rash
A 3-month-old, full-term male presents with a rash on his head for one day. The rash started on his forehead and spread to the rest of his head. Today, it developed a central clearing with surrounding redness. He has a history of sensitive skin since birth with patches of eczema and cradle cap which were treated with Aquaphor and Honest Co. Cream. He has no other symptoms and had an uncomplicated birth history. Diagnosis?
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Neonatal Lupus Erythematosus!
💥 An autoimmune disease caused by transplacental passage of maternal autoantibodies to Sjögren’s syndrome A or B autoantigens (SS-A/SS-B).
💥 Cutaneous findings of neonatal lupus most commonly present in the 1st month of life, but can present as late as 2-3 months.
💥 The cutaneous findings associated with neonatal lupus usually resolve in 4-6 months (when maternal antibodies are cleared from the infant’s circulation).
💥 Any baby with findings concerning for neonatal lupus should have an EKG performed. Around 2% of infants present with heart block postnatally within the 1st month.
Click link in bio for more info! 📲
https://www.aliem.com/saem-clinical-images-series-a-rare-pediatric-scalp-rash/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM Trick of the Trade: Chest Tube Rewarming with Foley Tubing Connector!
You have a pulseless hypothermic patient requiring aggressive internal rewarming. ECMO is not available, and you’ve made the decision to initiate thoracic lavage. After placing your chest tubes, you are left with large IV tubing in one hand for the warm IV fluids and a chest tube in the other with no time to waste, but no elegant or straightforward solution to interface the two. Trick of the Trade: Use Foley bag tubing! The tube from a standard Foley bag, available in all emergency departments, contains a Luer lock near the tapered nozzle. This unique connector setup allows you to instill warm fluids into the thoracic space with minimal spillage.
Click link in bio for more info! 📲
https://www.aliem.com/trick-chest-tube-rewarming-foley-tubing-connector-hypothermic-patient/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
The Febrile Infant: Incorporating the 2021 American Academy of Pediatrics Guidelines
In the most recent 2021 Clinical Practice Guidelines, the American Academy of Pediatrics (AAP) aims to provide guidance with 3 separate age-based algorithms for the evaluation and management of the well-appearing febrile infant.
Take-Home Points:
💥 These management strategies can only be used in WELL-APPEARING infants – if they’re ill-appearing, do a complete workup.
💥 Evaluation of febrile infants 0-21 days remains the same – do everything (blood culture, UA +/- culture, LP with CSF studies), give antibiotics, and admit.
💥 For those infants 22-28 days, get the UA, blood culture, and inflammatory markers to guide management. Not all febrile infants in the 22-28 day subset need an LP, though it should still be obtained in certain clinical circumstances, and discussed between provider and parents in other situations.
💥 In infants >28 days, a complete workup is still needed even if a viral source is present.
💥 Febrile infants 29-60 days old may be sent home after a negative workup with close follow-up.
Click the link in bio for a more detailed overview! 📲
https://www.aliem.com/the-febrile-infant/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM presents SAEM Clinical Image Series: My Shoulder Hurts
An 18-year-old male presents to the ED with right shoulder pain after wrestling with his brother. He heard a “pop,” and has been having pain along his right clavicle and shoulder since. He is unable to move his right shoulder. No numbness, tingling, or weakness in his arm or hand. He has no history of shoulder dislocation or fractures.
Given his exam with gross asymmetry and bogginess at the sternoclavicular joint, a CT scan was ordered which showed posterior sternoclavicular dislocation!
💥 Consider posterior sternoclavicular dislocation for those with traumatic shoulder or clavicular pain, particularly when the initial x-ray is unrevealing.
💥 Posterior sternoclavicular dislocation can have subtle exam findings that are easily missed if a high level of suspicion is not maintained.
💥 Posterior sternoclavicular dislocations can result in damage to underlying structures and require emergent orthopedic consultation for reduction in the OR with cardiothoracic backup available.
For more info, click link in bio! 📲
https://www.aliem.com/saem-clinical-images-series-my-shoulder-hurts/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM presents SAEM Clinical Image Series: A Rare Cause of Post-Traumatic Neck Pain
A 15-year-old male presents to the ED with neck pain for 3 weeks. He was assaulted 3 weeks ago and has had progressively worsening neck pain and stiffness. He is now unable to turn his head but denies fevers, chills, focal weakness, or sensory changes. Vitals were normal. Exam showed cervical midline tenderness with rigid neck and severe tenderness with manipulation; no swelling, erythema, or masses.
The CT showed joint space narrowing and erosion (red arrow) of the right AO joint with associated soft tissue swelling and effusion. He was found to have septic arthritis of the atlantooccipital (AO) joint.
Take-Home Points:
💥 Septic arthritis of the cervical facet joints is a rare cause of neck pain in patients with fever and elevated inflammatory markers, and can present after trauma.
💥 Generally, it is hematogenously spread and associated with comorbidities such as diabetes, IV drug use, and immunosuppression. However, it should be considered in patients with refractory symptoms or in which there is strong suspicion as it can have dangerous complications.
💥 MRI is the preferred imaging modality, though CT can be useful. Treatment generally consists of weeks of IV antibiotics and possibly surgery.
Click link in bio for more info! 📲
https://www.aliem.com/saem-clinical-images-series-a-rare-cause-of-post-traumatic-neck-pain/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM presents SAEM Clinical Image Series: An Adult with a Lower Extremity Rash
A 37-year-old man with type 2 diabetes presents to the Emergency Department with a rash. Initial symptoms began one week prior with small spots on the right leg with associated itching and burning. He initially presented to an outside facility where he was diagnosed with an allergic reaction versus scabies and was given a short course of oral steroids and topical permethrin that provided some relief. The rash progressed to bilateral lower extremities prompting re-presentation to the ED. He also reports associated dark urine and nausea. What is the most likely diagnosis?
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IgA vasculitis, formerly called Henoch-Schonlein purpura or HSP!
💥 The diagnosis is suspected when a patient has purpuric skin lesions predominantly on the lower limbs with at least one of the following: abdominal pain, joint involvement, renal involvement (proteinuria/hematuria), and/or biopsy demonstrating IgA deposition.
💥 This vasculitis is more commonly seen in children and has a male predominance.
💥 In adults, renal involvement is more common and often more severe.
Click link in bio for more info! 📲
https://www.aliem.com/saem-clinical-images-series-adult-lower-extremity-rash/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM is back with another SplintER Series!
A 46-year-old woman with a history of diabetes and obesity presents to the emergency department with difficulty walking after she tripped on a curb and fell onto her right knee. X-rays are obtained. What is your suspected diagnosis? What is your management and disposition?
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Patellar tendon rupture!
Management and disposition:
All patients should be immobilized in a non-hinged knee immobilizer or posterior long leg splint, made non-weight bearing, and given crutches. Orthopedic surgery does not typically need to be consulted in the emergency department. Patients should be seen by an orthopedic surgeon within two weeks of injury.
Click link in bio for more info! 📲
https://www.aliem.com/splinter-series-patellar-tendon-rupture/
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #residentlife #medschool #Emergency
ALiEM is back with another #ACMT from #ToxicologyPearl: Swollen Lips
A friend texts you a photo of their child who had an accidental ingestion. What is the likely cause of this finding?
Potassium Hydroxide:
- Decontamination should occur if indicated with attention to preventing secondary exposure to caregivers
- Patients may have few initial symptoms with a severe gastrointestinal tract injury
- Watch carefully for respiratory compromise due to upper airway edema.
- CT imaging may be useful to evaluate for perforation, hemorrhage, and burns.
- EGD is the gold standard to identify, evaluate, and plan for management for the caustic injury. This should ideally performed within 24 hours of ingestion.
Remember to click the link in bio for full article! 📲
#FOAMEd #FOAM #EmergencyMedicine #MedicalEducation #medicalstudent #patientcare #physicianassistant #nursepractitioner #emergencyroom #residentlife #medschool #Procedures #Emergency #ALiEM #MedEd #Toxicology
https://www.aliem.com/acmt-toxicology-visual-pearl-swollen-lips/
Also check out the Instagram feed by Dr. Michelle Lin.
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
@M_Lin
Latest posts by Michelle Lin, MD (see all)
- EM Match Advice 40: Program Directors Reflect on the 2023 Match - May 17, 2023
- EM Match Advice 39: Mailbag Q&A as a Mid-Interview Season Check-In - December 30, 2022
- EM Match Advice Podcast: Mid-Interview Season Check-In | We want to hear from you - November 29, 2022