quick H2-blocker reference

17 Apr

quick-reference chart put together for your use in a pinch.  I frequently found myself double-checking some of the generic/trade name crossover, and the IV/PO first-dosing at times, so figured this might be helpful for others as well.  Here it is, as a chart and photo.




Generic Name Cimetidine Ranitidine Famotidine Nizatidine
Brand Name Tagamet Zantac Pepcid Axid
equivalent dosing (left-to-right)
PO (avg dose) 400mg 150mg 20mg 150mg
PO (big dose) 800mg 300mg 40mg 300mg
IV 300mg IV 50mg IV 20mg IV


References: UIC pharm referencegihealth patient education site

Special Skills for Reducing Distal Radius Fractures, Part II: Finger Traps.

15 Apr


Colles’ Fractures, wrist fractures with dorsal and lateral dislocation of the radius, often have an element of
radial shortening”. This refers to the length of the radius comparing the carpal articular surface of the ulna and the lunate fossa of the radius.

If the radius is proximal to a line drawn across the end of the ulna the radius is shortened (yellow arrow).  


What to do????wrist2


Finger traps are meant to elongate a shortnened radius.





  • Place the patient supine, with the HOB flatwrist3
  • Flex the elbow to 90 degrees
  • The goal is to achieve radial tilt, so include no more than the first three digits (1&2 or 1-3)
  • Hang 15lb weight from the upper arm (distal humerus)
  • Adequate fracture reduction is considered with

o   <2mm articular step off

o   <20 degree of volar angulation

o   <3mm radial shortening


References: Text & Picture 1-2 ERcast.org; Picture 3


Submitted by K Estes.

Special Skills for Reducing Distal Radius Fractures, Part I: Hematoma Block.

14 Apr

A Colles’ fracture is the most common type of wrist fracture; located at the distal radius with the lower rads1radial fragment dislocated dorsally and laterally


Indications: clean, closed fracture site



  • Prepare skin with clorhexadine or betadine
  • Prepare 5-10cc lidocaine (1-2% without epi)
  • Inject the needle into the fracture site, aspirate, and observe flash back of blood
  • Reinject with aspirated fluid a few times


Adequate anesthesia occurs in 5-10 minutes and lasts for several hours.


Consider using the hematoma block for your other orthopedic procedures such as ankle dislocation, phalanx fracture or dislocation.


References: Text & Picture 1-Roberts & Hedges; Picture 2- Managing Colles’ Fractures in Rural Practice. Canadian Journal of Rural Medicine. 1998. Vol 3 (1):20-25.


Submitted by K Estes.

Skin Complaints in the Returning Traveler

11 Apr

Typically caused by:

-exacerbations of pre-existing disease (atopic dermatitis, psoriasis, etc.)

-environmental conditions (photosensitivity, contact allergies, etc.)

-infective organisms


Most rashes are minor problems such as sunburn and insect bites, and are self-limiting requiring only symptomatic care.


Top 10 tropical travel dermatoses requiring specific therapy:

-cutaneous larva migrans

-pyodermas (due to staph or strep)

-arthropod-reactive dermatoses

-myiasis (infection with a fly larva)

-tungiasis (infestation by burrowing flea)


-febrile syndromes with rash

-cutaneous leishmaniasis


-fungal infections


rash1Elevated, serpiginous, reddish-brown lesion of cutaneous larva migrans.
leishOld world cutaneous leishmaniasis ulcer.


Syndromes to be on the lookout for…

Fever and rash (petechial or hemorrhagic): dengue fever, arboviruses, rickettsial infections (e.g., scrub typhus), meningococcemia, leptospirosis, malaria, and erythema multiforme caused by drug reaction or common infection
Papules: insect bites, persistent lesions (chiggers), scabies, allergic drug reactions, cercarial dermatitis (swimmers), Pseudomonas folliculitis (hot-tubbing), onchocerciasis (long-term travel)
Nodules: furunculosis, myiasis (movement within the lesion), chancroid, syphilis, systemic parasites/fungi
Migratory: cutaneous larva migrans, strongyloidiasis (fast-moving and often on the buttocks), urticaria from various causes, and Loa loa (rarely)
Ulcerative: pyodermas, spider bites, chancroid and syphilis, cutaneous leishmaniasis



-rarely is it necessary to recommend anything more than symptomatic care in the ED

-referral to your local infectious disease or tropical medicine clinic for suspicious or chronic lesions


Submitted by K. Estes.

References: Tintinalli’s Emergency Medicine:  7th Edition; uptodate.com (pictures)

Clavicle Fractures

10 Apr

Classified into 3 groups

  • -medial third (uncommon, ~5%)

o   think about associated pneumothorax or pulmonary injuries

  • -middle third (most common, ~80%)

o   shoulder typically presents downward, forward, and inward due to pull from pectoralis major and latissiumus dorsi on the distal fragment; proximal component pulled upward due to sternocleidomastoid

  • -lateral third (~15%), further classified into subtypes

o   Type I - stable, minimally displaced due to intact coracoclavicular (CC) ligament

o   Type II - torn CC  ligament, tend to displace due to lack of stabilizing force proximally

o   Type III - involve the articular surface



  • immediate orthopedic consultation for
    • open fractures,
    • associated neurovascular injuries (rare; however injury to the subclavian vessels and the brachial plexus is possible),
    • skin tenting (impending open fracture!),
    • interposition of soft tissues 


  • higher incidence of nonunion and more likely to require surgery (think more urgent follow-up)

o   type II lateral clavicle fractures (up to 30% nonunion)

o   severely comminuted or displaced fractures of the middle third (defined as >20mm shortening)


XR showing complete displacement of a middle-third fracture of the left clavicle with marked shortening (over 40mm).


  • most heal uneventfully and can be discharged in a simple sling with outpatient follow-up

o   a sling should be worn until repeat XR shows callus formation and healing across the fracture site

o   early passive range of motion exercises are encouraged to reduce the risk of adhesive capsulitis (“frozen shoulder”)

o   younger children require shorter periods of immobilization (2-4 weeks) than adolescents and adults (4-8 weeks)


Submitted by K. Estes. 


Reference:  Rosen’s Emergency Medicine:  7th Edition, uptodate.com (picture)



orthostatic vital signs in blood donors

8 Apr

orthostatic vital signs in 100 blood donors sustaining an acute 450-mL blood loss.

same parameters were measured in the same arm beginning 30 seconds after standing.

orthostatic vital signs was repeated immediately after blood donation.


Mean orthostatic vital sign changes were as follows:

  • pulse rate, 2 ± 7 beats per minute;
  • systolic blood pressure, −3 ± 9 mm Hg;
  • diastolic blood pressure, 1 ± 7 mm Hg.
Not a dramatic change.  Wouln’t really meet most “orthostatic hypotension” vital sign criteria.

Also, for those known to be orthostatic, a pulse rise of >20 beats per minute +/- diastolic blood pressure fall >10mm Hg had high specificity but poor sensitivity.

how important is that journal (article)?

4 Apr


how its calculated:

A = number of times articles published in 2011-2012 were cited in indexed journals during 2013

B = the number of articles, reviews, proceedings or notes published in 2011-2012

impact factor 2013 = A/B

(translation: if the articles from that journal are cited a lot, the impact factor is higher)



this site appears to have collected a lot of the medical journal impact factors for 2013

here are the emergency medicine journals, for your own perusement:


References: impact factor site; picture


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