Trick of the Trade: Hip dislocation Part II
As a followup to the blog on the Captain Morgan technique for hip dislocations, I’d like to throw out another similar technique that also does NOT involve climbing up on the gurney.
Trick of the Trade: Captain Morgan technique for hip dislocation
Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient’s bed.
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Paucis Verbis: Acute vestibular syndrome and HINTS exam
What is your diagnostic approach to the acutely vertiginous patient?
The bottom-line question is: Is the cause peripheral or central in etiology?
In this great 2011 systematic review article in CMAJ on Acute Vestibular Syndrome (AVS), the authors review how (un)predictive elements of the history and physical exam are. By definition of AVS, symptoms must be continuous for at least 24 hours and have no focal neurologic deficits.
Frighteningly, the authors report many of the signs and symptoms (type of dizziness, hearing loss, patterns of nystagmus, Hallpike-Dix) are not as predictive as we classically are taught!
The take home point is to learn and incorporate the 3-part HINTS exam into your diagnostic approach (see bottom box on card). It is reported to be as good as a diffusion-weighted MRI for diagnosing a posterior stroke. The steps are:
- Do the horizontal head impulse test. (Normal = central cause)
- Check for directionally-alternating nystagmus movement on left and right gaze.
- Do the alternate cover test.
PV Card: Acute Vestibular Syndrome vs Stroke | The HINTS Exam
Adapted from [1]
Go to ALiEM Cards for more resources.
There is a helpful 10-minute video showing normal and abnormal HINT findings:
- Head impulse testing
- Nystagmus testing
- Testing of skew
VIDEO LINK: http://emcrit.org/misc/posterior-stroke-video/
Thanks to Dr. Brian Resler (UCSF-SFGH EM resident) for giving me the heads up about this at Followup Conference!
Reference
- Tarnutzer A, Berkowitz A, Robinson K, Hsieh Y, Newman-Toker D. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183(9):E571-92. [PubMed]
Paucis Verbis: aVR Lead on ECG
What lead is the most overlooked on the ECG?
Answer: aVR Lead
This lead can provide some unique insight into 5 different conditions:
- Acute MI
- Pericarditis
- Tricyclic antidepressant (TCA) and TCA-like overdose
- AVRT in narrow complex tachycardias
- Differentiating VT from SVT with aberrancy in wide complex tachycardias by using the Vereckei criteria (possibly better than Brugada criteria)
PV Card: The aVR Lead on ECG
Adapted from [1-4]
Go to ALiEM (PV) Cards for more resources.
See also:
References
- Williamson K, Mattu A, Plautz C, Binder A, Brady W. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006;24(7):864-874. [PubMed]
- Vereckei A, Duray G, Szénási G, Altemose G, Miller J. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98. [PubMed]
- Kireyev D, Arkhipov M, Zador S, Paris J, Boden W. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010;15(2):175-180. [PubMed]
- Riera A, Ferreira C, Ferreira F, et al. Clinical value of lead aVR. Ann Noninvasive Electrocardiol. 2011;16(3):295-302. [PubMed]
Trick of the trade: Foley catheter for DUB
Your next patient has heavy dysfunctional uterine bleeding (DUB). She is tachycardic and pre-syncopal. While you establish an IV, resuscitate her, and wait for the gynaecology team to arrive, is there any trick you can use to stem the bleeding?
Paucis Verbis: Methotrexate for ectopic pregnancy
Ectopic pregnancies account for as many as 18% of patients who present with first-trimester bleeding or abdominal pain in the Emergency Department. This Paucis Verbis card summarizes the 2008 American College of Obstetricians and Gynecologists (ACOG) guidelines on the use of methotrexate (MTX) for ectopic pregnancies. Not all ectopic pregnancies require operative management.
What are the indications and contraindications to MTX? When should they follow up with their obstetrician?
Answer: In 4 days for a repeat b-HCG and possible second dose of MTX
Note that one of the eligibility criteria is that the patient must have an “unruptured ectopic pregnancy”. Many would consider that any ultrasonographic evidence of free fluid may be a sign of an early rupture. It is left up to clinician judgment in how “unruptured” is interpreted.
PV Card: Methotrexate for Ectopic Pregnancy
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Reference
- ACOG Practice Bulletin No. 94: Medical Management of Ectopic Pregnancy. Obstetrics & Gynecology. 2008;111(6):1479-1485. doi: 10.1097/aog.0b013e31817d201e
Trick of the Trade: Ultrasound-guided injection for shoulder dislocation
Who loves relocating shoulder dislocations as much as I do? I know you do.
Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.
How can you improve your success rate in injecting into glenohumeral joint injection?