A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. “It feels different than my RA flare.”
You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.
Is your first-line treatment meclizine or benzodiazepines?
The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).
- Place the gurney’s head of the bed down flat.
- Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney.
- Rotate patient’s head 45 degrees.
- Help the patient lie down backwards quickly.
- The patient’s head should be hanging off of the gurney edge in about 20 degrees extension.
- Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV.
I find 2 things challenging in this maneuver.
- The patient often does not like to be moved AT ALL while feeling nauseously vertiginous. This even includes trying to reposition the seated patient closer to the head of the bed. This requires them to look behind them to see what where they are going, which sets off more vertigo.
- In some of our ED rooms and hallways, the head of the gurney bed is often abutting a wall, a portable monitor, or some equipment. It takes a little fancy shuffling to make room for the Dix-Hallpike maneuver.
Trick of the Trade: A modified Dix-Hallpike maneuver
The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients’ shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I’m sure the patient would appreciate keeping their head movement to a minimum.
Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is the sciatic nerve.
One of the indications for nasogastric (NG) tube placement is to instill fluids or medications. This may be saline or water for NG lavages or charcoal. You can manually push fluids into the NG tube via a 60 cc syringe, but this may take a long time for large volumes.
One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?
Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.