Posterior Lateral Maleolus, My Old Friend

Source: See citation below Pearl:  When applying the Ottawa Ankle Rule, we specifically palpate the posterior maleoli. Explanation: When reviewing the Ottawa Ankle Rule today during morning report the question came up: why do we specifically palpate the posterior lateral and medial maleoli to assess for bony tenderness? The image above, from the initial derivation study andRead more

The 52 in 52 Review: CT Before LP?

Note: Some of the junior residents are unaware of what the 52 in 52 Review is. In brief. The ALIEM blog picked a list of 52 influential papers in EM (we are on version 2 now) to provide a weekly reading topic. The full list is available here. Article Citation: Hasbun R, Abrahams J, Jekel J, QuagliarelloRead more

Esmolol for Refractory VFib

By Jer5150 – Own work, CC BY-SA 3.0, Pearl: In cardiac arrest, consider esmolol (500mcg/kg loading dose, then 0-100mcg/kg/min drip) for refractory ventricular fibrillation. Background: Ventricular fibrillation is one of our two “shockable” rhythms and is supposed to portend a better cardiac arrest outcome. But what if your patient is refractory to standard treatmentRead more

Very Expensive Stickers

My Hospital computer would not permit an image pertinent to this post to be downloaded without admin privileges, so here is a photo of Quinoa. Pearl: Lidoderm 4% patches are available over the counter. Lidoderm 5% patches are prescription only. Background: There are decent data that for certain indications (post-herpetic neuralgia, neuropathic pain) that topicalRead more

Tetanus Booster: Like water or wine?

(1) Pearl: If forced to ration, the evidence may support targeting tetanus boosters among our ED wounded to patients in the following categories: A) Any wound and over 50 or never immunized B) Grossly soiled/crushed wound and >5 years since booster C) Any wound and >15-20 years since booster Background: The CDC recommends that following the initialRead more

The 52 in 52 Review: SCIWORA (and NEXUS) and SCIWOCTET

Note: Last week’s article, as selected by 52 in 52, was the NEXUS study methodology. I erroneously assumed that the other NEXUS article would be the results, but it was not. I don’t want to leave everyone with a cliffhanger, so here are the NEXUS study results: Sensitivity 98-99%, Specificity 12.9%, PPV 2.7%, NPV 99.8%.Read more

Tetanus Week Post 1: Complicating Matters

Risus Sardonicus. (1) Welcome to Tetanus Week! Tetanus is something we deal with every day but to which we give little educational thought. That changes this week. Up first: Are you giving the right medication? Pearl: Patients who were incompletely immunized and have high-risk wounds require tetanus immunoglobulin (TIG) in addition to a tetanus toxoid basedRead more

TXA for Uterine Hemorrhage

By James Heilman, MD – Own work, CC BY-SA 4.0, Pearl: TXA can be used for post-partum hemorrhage. Its utility for other forms of gynecologic bleeding is unclear. Background: TXA (Tranexamic Acid) now has an established role in controlling the hemorrhagic shock of a trauma patient after the CRASH-2 trial. I recently cared forRead more

If you don’t suspect, don’t collect.

Intraluminal Catheter Encrustation. Photo Credit: Royal Society of Chemistry. Pearl: There is likely little advantage gained from treating asymptomatic bacteriuria in patients with chronic indwelling foley cathethers. If you will not treat it, you probably should refrain from testing it. Question: Some like to play fast-and-loose with the bacteria found in chronic indwelling foleys. If youRead more

The 52 in 52 Review: Nexus Criteria (Methods)

Brief Note: This article is a methods-only paper. The results of the Nexus study will be discussed in next week’s 52-in-52 Pearl. Article Citation: Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998 Oct;32(4):461-9. PMID: 9774931 What WeRead more