Serum lidocaine levels correlate well with observed clinical effects. As the concentration increases, lightheadedness, tremors, hallucinations, seizures, and cardiac arrest can occur. Levels > 5 mcg/mL are associated with serious toxicity. With so many concentrations (1%, 2%, 4%) and routes of administration available, the total dose of lidocaine is always a concern.
A fiberoptic nasopharyngoscope is a handy tool to check patients for suspected foreign bodies (e.g. fishbone stuck in throat) or laryngeal edema. Depending on the diameter of your fiberoptic cable, it may be fairly uncomfortable for the patient despite generous viscous lidocaine instillation through the nares and nebulized lidocaine. Alternatively or additionally, you can make your own lidocaine-oxymetazoline nasal atomizer which works well.
What if the patient is STILL not tolerating the procedure well?
Sometimes classic techniques need to be revisited, especially when I get new photos from the collective readership. Let’s review a painless way to remove beads from the ear canal. You can’t exactly have the patient’s provider blow in the other ear to expulse the bead, similar to a nasal foreign body…
Three weeks ago, I talked about more safely reducing mandibular dislocations. After successful completion of the procedure, how do you make sure that the patient doesn’t re-dislocate the mandible? You definitely should tell the patient to keep their jaw closed as much as possible for the next 24 hours and avoid opening the mouth widely (eg. yawning/laughing).
How do you immobilize the mandible? Especially for the chronic dislocators, presumably with more lax TMJ ligaments, you should think about immobilization. This can be done with a head bandage which goes under the chin. You can use kerlix rolls or an ACE wrap.
Does anyone think that this is generally a bad idea when closed-reducing mandible dislocations? Yes, it’s easiest to apply downward pressure on the mandible by pushing down on the occlusal surfaces of the molar teeth. Sometimes, however, when the mandible relocates into place, the teeth clamp shut abruptly – placing your thumbs at risk. How can you prevent any injuries to yourself?
One way is to slide gauze into the mouth during your procedure. Start the video around the 1:30 mark for an exam.
Trick of the Trade: Mandible Relocations
Apply a protective roll of gauze over each thumb. Additionally, you can wear a second glove to cover the gauze. No, those are NOT just fat thumbs under the gloves.
A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion. An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter. I can never find syringes with the side rings to allow you to grasp the syringe more securely with one hand (see photo above).