LET – not just for lacs

LET gel, a combination of 4% lidocaine, 0.1% (1:1000) epinephrine, and 0.5% tetracaine in a methylcellulose gel, is commonly used as a topical anesthetic for the repair of skin lacerations, especially in children. It often eliminates the need for injected local anesthetic, but also alleviates the discomfort associated with lidocaine injection when it is required.Read more

Pigtail Catheters for Pneumothorax

A patient presents 3 days after a lung biopsy with shortness of breath and chest pain. He has a normal HR and BP but SpO2 is 92% on non-rebreather at 15lpm. On bedside ultrasound, he has absent lung sliding on the right, and CXR confirms a large pneumothorax without midline shift, pictured above. In additionRead more

When to give activated charcoal

A patient presents 30 minutes after intentional ingestion of 25 tabs of alprazolam. He is awake and talking, with normal vitals. This is a perfect situation in which to give activated charcoal, something that seems to be often discussed but infrequently given. Below is a quick overview of activated charcoal administration:   Mechanism of action: primarilyRead more

Contradicting studies on Door-to-diuretic time

Hot off the press is a new study evaluating the effect of door-to-diuretic time on in-hospital mortality in patients presenting with acute heart failure. This study was closely modeled after a prior study by Matsue et al last year (reviewed in this pearl) that found that lasix administration within 60 minutes of ED arrival wasRead more

Plasmalyte in hyperkalemia

A patient with end-stage renal disease on dialysis presents with hypotension and sepsis. He is also hyperkalemic. How do you fluid resuscitate him? Prior teaching was to never give potassium-containing solutions to a hyperkalemic patient. However, acidosis will further shift potassium extracellularly, and normal saline has a pH of 5.6, significantly lower than the physiologicRead more

Painless Foley insertion

A 57yo M presents with new onset urinary retention for 3 days. The triage nurse attempts to place a foley catheter but is unable to pass it. Bedside ultrasound confirms a distended bladder. The patient is now complaining of urethral discomfort and his urinary obstruction has still not been relieved. Ketorolac has minimally helped his pain,Read more

DAWN of a new era in stroke care

Thrombectomy performed within 6 hours of symptom onset has been demonstrated to significantly improve clinical outcomes after stroke. Though there is generally diminishing benefit with increased time interval from last known well to the time of intervention, some previous data suggested that patients with “salvageable” brain tissue on diffusion weighted imaging (DWI) may still benefitRead more

Age adjusted D-dimer – do units matter?

The use of an age-adjusted D-dimer cutoff in ruling out venous thromboembolism for patients over the age of 50 is now largely accepted. Most commonly, the age-adjusted dimer cutoff is calculated based on the patient’s age x 10 (e.g. the age-adjusted upper limit of normal for a 70-year-old patient is 700). This makes sense whenRead more

Kayexalate in Hyperkalemia – to give or not to give?

When a patient presents with hyperkalemia, in addition to the initial steps of obtaining an EKG and treating with calcium, insulin, glucose, albuterol, and furosemide if indicated, consultants will often ask us to also administer sodium polystyrene sulfonate, more commonly known as kayexalate, pending hemodialysis. Is this management strategy supported by evidence? Reviewing the (ratherRead more

C1 Esterase Inhibitor Deficiency

A 67 year-old man presents with lower lip swelling for the past two hours, and tells you he was recently diagnosed with acquired C1 esterase inhibitor deficiency. He has normal vitals, is speaking in full sentences, and denies any sensation of tongue or airway swelling. What do you do next? Easy, right? In addition toRead more