A 32-year-old female presents to the emergency department with right foot pain after rolling her ankle during dance class. On exam, there is mild swelling and tenderness over the 5th metatarsal. The above x-ray was obtained (Figure 1: Case courtesy of Dr. Henry Knipe, Radiopaedia.org, rID: 28104). (more…)
A 67-year-old male with a history of bilateral total hip arthroplasties (THA) several years ago presents with left hip pain after a fall. He was walking downstairs and slipped, twisting his leg internally and with adduction and flexion of the hip to catch himself. He denies falling but felt an immediate pop in his left hip and could no longer bear weight. AP and lateral radiographs of the pelvis and left hip were obtained and are shown above (Image 1. Case courtesy of Dr Andrew Taylor, Radiopaedia.org, rID: 67457). (more…)
A 23-year-old male presents to the emergency department with right ankle pain after he rolled his ankle while walking down the stairs. An ankle exam reveals ecchymosis over the posterior ankle and tenderness of the distal tibia. His neurovascular exam is intact. The radiograph above was obtained (Image 1. X-ray right ankle. Original image provided by Justine Ko, MD).
There are many ways to manage epistaxis. Once nasal clamping and cauterization fail, the next step is to consider using tranexamic acid (TXA) and performing nasal packing. Inflatable packing devices such as a Rhinorocket are painful to insert and do not conform well to the shape of the naris. The expandable Merocel nasal packing, a compressed, dehydrated sponge, provides a softer, alternative option, although the insertion process can be painful given its initial rigid, edged structure. We propose 2 strategic tricks to optimize your nasal packing technique using the Merocel sponge.
The common approach for Merocel packing involves inserting the unexpanded sponge into the nose, tilting the patient’s head back, and dripping in TXA solution to expand the sponge to tamponade the bleeding.
Trick #1: Wet the tip of the Merocel’s sharp edge to allow for a softer cushion to slide the packing more comfortably and deeper into the naris.
Trick #2: Use an angiocatheter to deliver the TXA solution directly onto the mid-portion of the packing. Commonly, the TXA solution is dripped onto the outer end, which may cause an uneven and inadequate expansion at the site where the bleeding may be occurring. Because blood also can react with the packing, it is likely the blood will expand the packing before TXA reaches the center by osmosis. Another benefit of Merocel expansion starting at the center is that it will help anchor the sponge in place. In contrast, TXA administration at the outer tip first may pull the sponge out of the naris a few millimeters.
1. Insert the angiocatheter needle into the Merocel packing about ⅓ the distance from the external end of the packing. Remove the needle, leaving the plastic angiocatheter in place.
2. Soak the insertion tip of the nasal packing with a drop of TXA to soften it. Or apply a light coat of an antibiotic ointment or petroleum jelly to the insertion tip for lubrication. This will make it easier to advance the packing and also less painful for patients. Advance the Merocel into the affected naris just as you would a nasogastric tube. Some additional tips are in the ALiEM article about nasogastric and nasopharyngeal tube insertion.
3. Once the nasal packing is fully inserted, expand the sponge by administering TXA via the attached angiocatheter. The mid-portion of the sponge should expand first, thus preventing outward slippage of packing. Also TXA more quickly reaches the area of bleeding rather than from a more gradual osmotic effect when dripped in from the external tip.
A 38-year-old female presents to the ED with right shoulder pain after a fall directly onto that shoulder. She noticed immediate pain and difficulty moving the arm associated with mild tingling in her right fingers. The radiographs above were obtained in the ED (Image 1. AP and lateral radiographs of the right shoulder, author’s own images).
A 20-year-old male distance runner who was jogging and happened to be running past the emergency department presented with severe bilateral leg pain, foot pain, and foot numbness that had resolved by the time he was evaluated in the ED. The x-ray above was obtained (Image 1. X-ray of the leg. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 41408).