Archive | April, 2015

strength in numbers: dizziness

23 Apr

Cribbed from this March ACEP Now article:


DIZZINESS/VERTIGO: numbers to consider

clinical factors associated with stroke in vertiginous patients

  • gait instability: Odds Ratio (OR) 9.3
  • subtle neurological findings: OR 8.7


predictors for serious neurological disease with complaint of dizziness, vertigo, or imbalance

  • Focal neurological abnormalities: OR 5.9
  • 60 years of age or older: OR 5.7
  • Imbalance: OR 5.9
  • Isolated dizziness: OR 0.20  (i.e. 80% less likely to be experiencing a serious neurological cause)


Study of 1681 pts w/dizziness:

  • CTs obtained in 48%
  • MRI’s in 5%


  • cost associated with identifying one abnormal CT: $165k
  • cost associated with identifying one abnormal MRI: $22k
  • all patients with positive CT or MRI had headache, neuro findings on exam, or optho complaints



  • don’t skimp on the neuro exam
  • walk (gait test) your dizzy patients


References: ACEP Now Article; picture

syringe TMJ reduction

16 Apr

cool trick from a 2014 JEM article:


TMJ dislocation:

  • commonly from excessive mouth opening (e.g. yawning, laughing)
  • anterior TMJ dislocations most common (non-traumatic)



  • 30/31 successful reductions (all anterior dislocations)
  • 77% took < 1 min


  • take 5-10 mL syringe
  • pt gently bites down on syringe (placed across molars)
  • ask pt to roll syringe back & forth



  • hands-free (no bite risk to provider)
  • quick
  • no procedural sedation needed


Seems pretty cool.  Add it to the toolbox.


References: JEM article; picture

visual aid: quick pressor reference

14 Apr

good refresher aid from March’s Emergency Medicine mag below.  The article goes through each pressor a bit more in depth, but the table here is a nice quick reminder of receptor activity and dosing, particularly with dopamine, which can have different effects at lower or higher doses.



References: article including table.

neat trick: morgan lens for lateral canthotomy

9 Apr

from March’s ACEP Now:

couple neat tricks to keep in your back pocket for the rare but nerve-wracking procedure



place a Morgan lens to protect the globe from iatrogenic rupture

risk: corneal abrasion

benefit: less likely to poke the globe



bent paper clip to hook/retract the eyelid bluntly

easy to find, low-cost


There you go.


References: ACEP Now article + picture from article

strength in numbers: meningitis

7 Apr

just to keep you honest (highlights via this EMdocs article)

“classic triad” (fever, altered mental status, stiff neck)

  • 95% had fever,
  • 88% had neck stiffness,
  • 78% had altered mental status.
  • only 44% of patients with meningitis had all three 


Neck pain: 28% sensitivity

headache: 50% sensitivity


avoid minimizing afebrile patients, especially in the elderly population: as many as 18% of these patients with meningeal infection may be afebrile

Kernig and Brudzinski signs

  • 95% specificity
  • sensitivity is as low as 5%.


“jolt test” (headache accentuated by horizontal rotation of the head at a frequency of two to three times per second)

  •  sensitivities ranging from 97% to 21%


opening pressure: as many as 9% are less than 14 cm/H20


their conclusion: “Ultimately, outside of a positive CSF culture, no one test or exam should rule in or out the diagnosis of meningitis
References: emdocs article; picture

visual aid: Seidel sign

3 Apr

(repost, but a good timely refresher)


look for a Seidel’s sign: leaking fluid from the eye/globe on fluorescein exam



came across these nice videos on the magical internet, check out the first video if you can only spare a few seconds.  check out the 2nd video for some voiceover and a little more detail.




References: video 1; video 2