Recall the last time you were sitting in a room doing a large-volume, therapeutic paracentesis in the ED. Were you stressing out because your other patients were still being actively managed? Large-volume paracentesis is a common and important part of our practice, but often requires your dedicated time at the bedside. Additionally, what do you do if you do not have the fancy paracentesis kit or vacuum collection bottles?
A 5 year old boy comes in who has stuck a small unpopped popcorn kernel into each ear. My resident and I discuss different methods to try to get it out including an ear curette, tissue glue, suction, and calling the ear-nose-throat (ENT) specialist. The ear curette won’t work to get around and the kernels are smooth and hard to grasp and might cause trauma with swelling or bleeding. We quickly excluded irrigation because the kernel might swell more. Another method considered was a drop of tissue adhesive onto a q-tip stick to adhere onto the foreign body (FB) for extraction. We were a little leary of this however for fear of gluing the FB to the ear canal and suffering the wrath of ENT.
Venipuncture is the most common invasive procedure performed in the emergency department 1 , likely due to the fact that the vast majority of our laboratory evaluations require blood and many of our life saving interventions require access to the patient’s systemic circulation. Most of the time emergency department staff are able to perform this procedure easily, but occasionally you find that your patient is the dreaded “difficult stick”. Literature suggests that the landmark technique is successful on the initial venipuncture 74-77% of the time. 2–5 Success rates rise after multiple attempts, but what happens when you don’t have the luxury of time? What happens when your patient will die if you don’t get life saving medications into their circulation promptly? There are a few options when you can’t get IV access through traditional means, among them external jugular vein cannulation, central line, ultrasound-guided IV, and the intraosseous lines (IO).6 However, when managing the crashing patient, a wise decision is to use the quickest option, which is often the IO.
An 82-year-old female is brought into the Emergency Department by family for a several day history of progressive altered mental status. You initiate a broad workup. However, soon after initial evaluation, you are called back into the room. The patient’s vitals are as follows and concerning for septic shock and an alarming serum sodium level.
A 26-year-old woman presented to an urban Detroit emergency department complaining of bilateral foot pain after walking outside in the snow for 30 minutes without shoes or socks. She was unable to ambulate secondary to the pain and swelling. Physical examination revealed bilateral pallor, doughy texture, and coolness to the touch. There was generalized tenderness to palpation throughout the digits. The overlying skin was edematous, although without signs of breakdown.
Distal radius fractures are among the most commonly encountered fractures in the emergency department (ED). They have been reported to account for around 25% of pediatric fractures and up to 18% of fractures in the elderly.1 Reducing minimally displaced distal radius fractures is a procedure that can be greatly facilitated by the presence of finger traps, which help hold traction while you reduce the fracture.2 Often While working in small 5-bed, free-standing emergency department (ED), I found myself needing to perform this vital procedure and finger traps were unavailable.
Application of fluorescein is a vital part of the workup of ocular complaints. Despite some studies showing questionable support, the typical cited clinical concern for stored fluorescein solutions is contimination with Pseudomonas and risk for iatrogenic infection with associated ulcer formation. 1–4 Subsequently, single dose sterile strips have become the standard agent stocked in most EDs. Many patients, especially children, can be apprehensive of the application of the physical strip directly to the eye, and are more comfortable with the concept of eye drops. In this post, we review multiple technique to create fluorescein solutions and additional tips for utilization that may be integrated into your practice, depending on the supplies available to you.