Trick of the Trade: Managing Epistaxis with Merocel Nasal Packing and an Angiocatheter


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.

Trick of the Trade: Strategic expansion of 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.

Equipment

  • 20g or 22g angiocatheter (closed IV catheter system)
  • Tranexamic acid solution
  • A syringe
  • Merocel nasal dressing

Technique

merocel sponge nasal packing trick setup

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.

merocel tip moisten txa trick

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.

Trick of the Trade: Winging It with External Jugular Cannulation

external jugular

Sankoff J, et al. WJEM (2008)

Imagine yourself caring for a patient that needs urgent vascular access, but several attempts at peripheral intravenous (IV) cannulation have been unsuccessful. You aren’t quite at the point where emergent intraosseous or central venous access is indicated. Maybe those options aren’t even available where you’re working. From across the room, though, you can see a very prominent external jugular (EJ) vein. Sadly, you remember the last EJ line you placed falling out almost immediately.

Patients with challenging peripheral intravenous access in the extremities may require and benefit from cannulation of the EJ. Often done in the setting of resuscitation, securing these angiocatheters on the neck can be difficult. Tape and dressings may not stick due to sweat and anatomical limitations. Rotation, flexion, and extension of the neck can displace the catheter.

Trick of the Trade

If available, modify a winged angiocatheter to allow suturing to the skin of the neck.

angiocatheter


  • Create two small holes, one on each wing of the angiocatheter, using a sharp instrument such as scissors, scalpel, or needle.
  • Place EJ line and secure to the skin using sutures, similar to stabilization of central or arterial line.

Winged angiocatheters may not be available in all clinical institutions. International readers of ALiEM may be more familiar with their use.

However, this trick introduces the idea of finding creative modifications of available catheters to allow for suturing and securing of alternative IV lines. Modifications similar to this Trick of the Trade can be considered when placing “deep” peripheral IVs or pseudo-midline IVs such as when using extended-length angiocatheters or repurposed arterial catheters where suture can be wrapped around the hub. This approach may also be useful in peripheral cannulation of the internal jugular vein. 

Tip: Be careful not to pierce the catheter or compress it down when suturing.

More from ALiEM on EJ cannulation:

Interest in other tricks?

Read more articles in the Tricks of the Trade series.

By |2022-09-08T15:18:30-07:00Sep 9, 2022|Tricks of the Trade|

Trick of the Trade: Getting the last bit of ultrasound gel from the bottle

It’s a busy shift and you need to perform a bedside ultrasound on a patient’s belly to rule out cholecystitis, when you realize that the ultrasound gel bottle is nearly empty. No matter how many times you vigorously shake the bottle, it’s impossible to get the viscous gel out. In a pinch, you could use hand sanitizer, sterile lubricant, or even water as a substitute for gel. Or you could run to the storage room on the other side of the busy department to grab a new bottle. Or…

Trick of the Trade

Use centrifugal force to move the gel to the top of the bottle!

trick ultrasound bottle gel out


  • Turn the bottle upside down so the cap is facing the ground.
  • Place the bottle into a (fresh) patient’s sock or transducer cover. Alternatively, you can use a plastic bag or ortho tubular stockinette.
  • Firmly holding the bag, and spin the bag for a few seconds in a circular motion, almost like you were throwing a grappling hook.
  • The centrifugal motion will generate an outward force pushing all of the viscous gel to the bottle cap!
  • Once you’ve used the gel, store the bottle cap-side down so you don’t have to do this again.

This trick is useful in a pinch, because it makes use of the entire gel bottle and promotes an eco-friendly use of ED resources.

Tip: Just don’t let go while you swing, lest you turn that patient with the belly pain into a trauma activation from a bottle to the face.

Interest in other tricks?

Read more articles in the Tricks of the Trade series.

By |2022-07-25T11:26:09-07:00Jul 27, 2022|Tricks of the Trade, Ultrasound|

Trick of the Trade: A “Fiberbougie” through a supraglottic airway device (King tube)

king tubeResuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success [3]. Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could be blindly changed over a tube exchanger however it is quite easy to lose the airway completely during this process. We describe a potentially safer and more effective alternative.

Trick of the Trade

After a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide.

equipment fiberbougie king

Equipment Needed

  • Disposable bronchoscope
  • Endotracheal tube
  • 50 mL syringe
  • Laryngoscope (video or direct)
  • Trauma shears
  • Suction
  • Capnography
fiberbougie through supraglottic device king airway

Left: Demonstrating the technique inserting a single-use bronchoscope through a supraglottic King tube in a simulation patient. Right: Corresponding view of the vocal cords through the King side port in a real patient.

Description of the Trick

  1. Insert a disposable bronchoscope through the airway port of the King airway
  2. Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina
  3. Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina
  4. Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway
  5. Insert the endotracheal tube over the “fiberbougie”
  6. Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords
  7. Confirm placement with capnography and/or with direct visualization and x-ray
bronch bougie equipment

Insertion of the endotracheal tube over the “fiberbougie” with video laryngoscopy confirmation with a simulation patient. The inset image was captured from a Glidescope on a real patient during the exchange.

 

Video Tutorial of the Fiberbougie Technique to Exchange a King Tube

 

 

References

  1. April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039. PMID 33684505
  2. Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation Cardiovascular Collapse in Critically Ill Patients: Insights from the INTUBE Study [published online ahead of print, 2022 May 10]. Am J Respir Crit Care Med. 2022. doi:10.1164/rccm.202111-2575OC. PMID 35536310
  3. Burns JB Jr, Branson R, Barnes SL, Tsuei BJ. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):92-95. doi:10.1017/s1049023x00007743. PMID 20405470 

Trick of the Trade: Don’t fight the ultrasound cord for peripheral IV access

ultrasound POCUS peripheral iv trick

Ultrasound-guided IVs require hand-eye coordination and fine movements of probe in Goldilocks fashion. Apply too much pressure, and the vein in question is compressed. Slide a little to the right, and now it’s out of the window. Something that practitioners don’t think about is the tension from the cord. If left to its own devices, the cord will tug on the probe, making the probe harder to steer and handle, especially for those tiny veins.

Trick of the Trade: Reduce cord tension

Have the patient grasp the cord!

This makes them an active participant. Usually, if they are awake and good-humored, tell them “audience participation is required.” Doing so will give you enough slack to effectively visualize and troubleshoot the ultrasound-guided IV.

ultrasound cord trick POCUS

 

What if the patient is intubated, or altered, doesn’t quite grasp, or can’t handle the situation?

Tape the cord to the gurney side rail. Use a 2×2 gauze as a buffer between the tape and the rail so the tape doesn’t damage the cord itself.

ultrasound cord POCUS tape

 

Want to learn other tricks?

Read other articles in the Tricks of the Trade series.

By |2022-05-31T00:37:48-07:00Jun 3, 2022|Tricks of the Trade, Ultrasound|

Trick of the Trade: DIY Nasal Snot Aspirator

nasal bulb suction

Nasal congestion is a common symptom of upper respiratory tract infections, such as bronchiolitis, in newborns and infants. Because newborns are obligate nose breathers, any congestion presents a challenge during feeding and sleeping. These infants become frustrated when they cannot breathe while feeding and tend to have disturbed sleep when their nasal passages are occluded. This often leads to dehydration and irritability. Although the infant bulb syringe (above) can often alleviate the congestion, other commercial products may be able to more forcefully clean out the nasal mucus (e.g., NoseFrida, Bubzi Nasal Aspirator).

Trick of the Trade: DIY Nasal Snot Aspirator

In the Emergency Department, you may encounter families who may not have the resources to purchase or be aware of commercial aspiration devices for children. The concept behind our DIY Nasal Snot Aspirator is to allow the caregiver to suction the child’s nose using the negative pressure generated from the caregiver’s own mouth. The left video demonstrates how the NoseFrida works, and the right video demonstrates our DIY Nasal Snot Aspirator. Note that the specimen trap serves as the protective “filter”, or barrier, between the child’s suctioned mucus and the caregiver’s mouth. Thanks to Stephany Landry, RN, BSN for sharing this trick of the trade.

Equipment Needed: DIY nasal snot aspirator

  1. Left: Little Sucker Aspirator [Amazon]
  2. Middle: Short suction tubing
  3. Right: Mucous specimen trap, 40 cc [Amazon]
DIY Nasal Snot Aspirator equipment

Description of the Trick

  1. Suction tubing: Attach one end to the Little Sucker Aspirator and the other end to the short connector port on the specimen trap.
  2. Instill some saline drops into the child’s nose.
  3. Insert the aspirator tip of your contraption into the child’s nostril.
  4. Have the caregiver suck out through the “straw” attached on top of the specimen trap.
trick DIY nasal snot aspirator
DIY Nasal Snot Aspirator, demonstrated by Stephany Landry, RN, BSN

Disclosures

The authors and ALiEM do not have any affiliation with any of these device companies.

By |2022-01-21T01:18:17-08:00Jan 26, 2022|HEENT, Pediatrics, Tricks of the Trade|

Trick of Trade: Large-Bore Endotracheal Tube To Suction the Occluded Airway

vomit suction emesis pumpkin

The paramedics just arrived with a new patient to the resuscitation room. You find an altered patient actively vomiting bloody vomitus and food particles. You prepare for a difficult airway. You prepare 2 Yankauer suction catheters, but you are still worried that the food particles may clog up the catheters. Is there a better alternative?

Background

Up to 44% of emergent intubations are complicated by blood, vomit, or food particles in the airway. It has been shown that contaminated airways may lead to multiple intubation attempts and are associated with poor outcomes, such as peri-intubation cardiac arrest [1, 2].

The Yankauer suction catheter is the most commonly available tool in the Emergency Department to remove foreign particles, but performs poorly when compared to larger-bore catheters [3]. The Yankauer was made initially for surgical field management, with small holes at the tip to gently remove (or become clogged with) debris without damaging tissue. Some standard Yankauer designs have a built-in safety vent hole on the shaft, which if unoccluded, renders the device virtually useless [2]. This protective equipment design does not offer maximum help during emergent large-volume regurgitation dirty airway management.

Alternatively, there is the DuCanto suction catheter. It is a specialized and more expensive large-bore version of the Yankauer; however, it is not as readily available and more expensive [1].

Trick of the Trade: Use a large-bore endotracheal tube as a rigid suction catheter

A large-bore, such as a size 10.0, endotracheal tube can serve as a rigid suction catheter. Note the diameter sizes of the Yankauer, DuCanto, and 10.0 endotracheal tube below.

Suction devices (inner diameter):
Yankauer (3.56 mm), DuCanto (6.6 mm), 10.0 endotracheal tube (10 mm)
  • Materials needed
    1. Size 10.0 endotracheal tube (or the largest size you have)
    2. Suction tubing and canister
  • Making the device
    1. Insert the rubber end of the suction tubing over the plastic endotracheal tube adaptor
    2. Attach suction tubing to the canister
    3. Turn suction on

Video Demonstration: Yankauer vs Large-Bore Endotracheal Tube

Editorial Note: If the rigidity of the catheter is less important, you can also insert the soft suction tubing directly into the airway to remove contents.

Read other Tricks of the Trade posts on ALiEM.

References:

  1. Nikolla DA, Heslin A, King B, Carlson JN. Comparison of suction rates between a standard Yankauer and make-shift large bore suction catheters using a meconium aspirator and various sized endotracheal tubes. J Clin Anesth. 2021 Sep;72:110262. doi: 10.1016/j.jclinane.2021.110262. PMID 33839435
  2. Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-754.e2. doi:10.1016/j.annemergmed.2012.04.005. PMID 22542734
  3. Andreae MC, Cox RD, Shy BD, et al. 319 Yankauer Outperformed by Alternative Suction Devices in Evacuation of Simulated Emesis.” Ann Emerg Med. 68(4), S123 [research abstract] doi: 10.1016/j.annemergmed.2016.08.335
By |2021-10-29T19:15:35-07:00Oct 31, 2021|Critical Care/ Resus, Tricks of the Trade|
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