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Trick of the Trade: Improvised Collar and Cuff Sling Using Soft Limb Holders

Collar and cuff sling supporting the wrist with the elbow bent at 90 degrees

A 69-year-old woman presents to the emergency department (ED) after 2 falls at home. She tripped on a rug overnight, felt dizzy as she tried to get up, and fell again. She struck her head but has no pain from it. Her chief complaint is right shoulder pain, and she reports frequent shoulder dislocations in the past. An x-ray shows an acute comminuted, non-displaced fracture of the humeral neck with involvement of the greater tuberosity.

Initial management is immobilization in a sling for 1-3 weeks, and the evidence supports nonoperative treatment for most proximal humerus fractures [1,2]. A collar and cuff sling is an appropriate management plan to allow the elbow to hang free, so gravity applies gentle traction that helps maintain fracture alignment. However, what if your ED does not stock such a sling?

Trick of the Trade

Build a collar and cuff sling from 2 Posey soft limb holders, the padded wrist restraints most EDs already stock. In our case, this improvised collar and cuff sling provided adequate support to the wrist and a cushion for the patient’s neck.

Materials

2 Posey soft limb holders:

  • Use one complete holder.
  • Use only the padding from the second holder.
Two Posey soft limb holders laid flat, the materials for an improvised collar and cuff sling

Top padding from full Posey holder for the wrist; bottom padding from second Posey holder for neck collar

Steps

  • Wrap one cuff around the wrist of the injured arm.
  • Remove the padding from the second cuff, and thread that padding onto the long strap of the first cuff.
  • Pass the strap behind the patient’s neck. Slide the padding along the strap until it cushions the back of the neck. This is the collar.
  • Adjust the strap length so the elbow rests at 90 degrees with the wrist slightly above the elbow, and secure the buckle.
  • Improvised collar and cuff sling made from a Posey soft limb holder, worn with the elbow at 90 degrees and the wrist supported
Improvised collar and cuff sling made from a Posey soft limb holder, worn with the elbow at 90 degrees and the wrist supported

Improvised collar and cuff setup

Tips

  • Application of the padded neck collar is important, because the Posey strap is often thin, flat, and coarse. It can dig into the neck once it carries the weight of an arm over the next 1-3 weeks.
  • Support the wrist only and allow the elbow to hang to gravity. This axial traction helps to maintain fracture alignment.

Interested in More?

For a collar and cuff improvised with the neck strap from a shoulder immobilizer, plus other common ED splinting techniques, see SplintER Series: Common ED Splint Techniques 104.

 

References

  1. Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022;6(6):CD000434. doi: 10.1002/14651858.CD000434.pub5
  2. Rangan A, Handoll H, Brealey S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-1047. doi: 10.1001/jama.2015.1629
By |2026-08-16T07:48:13-07:00Aug 16, 2026|Orthopedic, Tricks of the Trade|
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Trick of Trade: Using Sterile Lubricating Gel to Manage Bloody Scalp Lacerations | A Simple Gel, a Big Fix

scalp laceration bloody gel
One of the classic scenarios encountered in the emergency department involves an elderly patient with medium to long hair who sustains a scalp laceration after a ground-level fall. They often arrive hemodynamically stable and without bony crepitus, yet the wound itself is challenging to evaluate. During transport, clotted blood frequently becomes entangled in their hair, forming a dense mat that obscures the laceration. The care team—technicians, nurses, residents, and physicians alike—may spend several minutes painstakingly separating hair and pressing on a tender scalp in an effort to expose the wound. This process is uncomfortable for the patient, time-consuming for staff, and often leaves behind residual clot. In many cases, the fallback option is to shave the matted area, which achieves exposure but results in a visible cosmetic defect.

Trick of the Trade

Applying sterile lubricating gel as a pre-irrigation adjunct [1]. It softens the clot, separates matted hair, and makes the whole process faster and gentler.

Technical Procedure · Emergency Medicine

Sterile Gel in Scalp Prep

How It Works

When a scalp laceration is obscured by clotted blood and tangled hair:

  1. Inspect for debris or foreign bodies; give a quick rinse if needed.
  2. Apply a generous amount of sterile, water-soluble lubricating gel (e.g., glycerin- or propylene-glycol–based).
  3. Wait 3-5 minutes to allow the gel to hydrate and loosen the clot, though clot dissolution is usually visible within 10-20 sec.
  4. Gently massage the area to separate hair and soften the meshwork.
  5. Irrigate or wipe with wet gauze to clear the gel. Saline or tap water both work great.
  6. Proceed with standard wound cleansing and repair once the wound is visible and clean.

In our experience with over a dozen cases at a tertiary emergency department, we found that this technique improved visualization, reduced discomfort, and required less follow-up irrigation overall—without any reported complications.

Why It’s Useful

  • Less irrigation, less hassle: Adequate wound visualization can often be achieved with less irrigation fluid.
  • Resource resilience: Especially useful in rural, wilderness medicine, or international emergency settings where any irrigant may be limited.
  • Patient comfort: Reduces painful scraping and hair pulling, with particular benefit noted in pediatric patients.
  • Safety: Sterile lubricating gels are non-cytotoxic, bacteriostatic, and easy to rinse off with whatever clean fluid you have on hand.

Important Notes

This gel trick is an adjunct, not a replacement, for wound irrigation and mechanical debridement. Avoid using this as the sole cleaning step in contaminated wounds.

Take-Home Points

Sterile lubricating gel can simplify scalp laceration prep by loosening clot and separating hair before irrigation. It is safe, inexpensive, and already available in most EDs.

References

  1. Kang JK, Shin MS, Song JK, Yun BM. Hair control during scalp surgery using a sterile gel technique. Arch Aesthetic Plast Surg. 2018;24(1):46-48. doi:10.14730/aaps.2018.24.1.46
By |2026-03-11T14:06:47-07:00Mar 18, 2026|Trauma, Tricks of the Trade|
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Trick of the Trade: Cut IV extension tubing for 2-person ultrasound guided nerve block

illustration nerve block ultrasound guided needle

Ultrasound-guided procedures are difficult enough just identifying the anatomy. Performing a nerve block with the ultrasound in one hand and the needle in the other hand adds extra challenges. The simplest 1-person approach involves attaching a syringe with local anesthetic directly to the end of the procedural needle. A 2-person approach involves attach the syringe to a custom tubing-needle setup such as below. However, this custom setup may not be readily available.

IV and extension tubing attached to needle

Trick of Trade: Cut Standard IV Extension Tubing

Required equipment:

  • Ultrasound linear probe
  • 10 cc syringe
  • IV tubing
  • Procedural needle
  • Shears

IV extension injection port

Almost all standard IV extension tubing that connects IV fluid bags to a peripheral IV have an injection port near the downstream end.

  1. Clamp the IV tubing just upstream from the injection port and cut off all the unused upstream IV tubing.
  2. Attach a 10 cc syringe with local anesthetic to the injection port.
  3. Attach the other end of this IV tubing (Luer lock attachment) to the procedural needle.
  4. Prime the IV line with the anesthetic.
  5. Perform the nerve block with one person advancing the needle under ultrasound guidance, while the other person aspirates and injects the anesthetic when needed.

Video: 2-person ultrasound-guided nerve block with cut IV tubing

Bonus Tip: This approach is applicable to many procedures requiring aspiration or instillation of anesthetic, such as peritonsillar abscess aspiration.

Read more from the Tricks of the Trade series.

By |2024-10-23T07:23:46-07:00Oct 23, 2024|Neurology, Tricks of the Trade, Ultrasound|
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Trick of the Trade: Ultrarapid adenosine push for SVT with a pressure bag

With some things in life, speed is everything. Adenosine is one of those things. With an ultrafast half-life estimated to be between 0.6 to 10 seconds [1], parenterally administered adenosine needs to reach the cells of the AV-node and cardiac pacemaker cells in an expedited fashion to facilitate the termination of supraventricular tachycardias (SVTs).

Known Techniques of Adenosine Administration

Currently, there are 2-syringe and 1-syringe methods that are widely accepted for the administration of adenosine. Recent data suggests that they are non-inferior to each other [2].

Adenosine flush 2 syringe method

Classic 2-syringe method: Benefit = undiluted adenosine to the heart; Limitation = limited by the syringe flush volume [3]

adenosine single syringe method

1-syringe method: Benefit = large volume; Limitation = dilution of adenosine with IV fluid. Read more about the single syringe trick of the trade.

Trick of the Trade: Pressure bag setup

We propose administering undiluted adenosine in an ultra-rapid fashion via an in-line, primed saline tubing with a pressure bag setup.

adenosine iv tubing in y-injection site port

The unique aspect of the trick is to incorporate a high-pressure, unidirectional IV fluid administration system. It is similar to the 2-syringe system except that the flush syringe is replaced with high-pressure IV fluids.

How to set-up

  1. Setup a pressure bag with a primed saline line in the standard fashion.
  2. Close the roller clamp so that no IV fluid is flowing through the tubing.
  3. Attach the IV line to the patient’s angiocatheter.
  4. Attach a syringe with undiluted adenosine to the Y-site port as close to the patient’s IV as possible.
  5. Open the roller clamp to start the high-pressure IV fluid administration.
  6. Rapidly push the adenosine into the tubing.

Video demonstration

In this video, adenosine is the colored fluid for demonstration purposes. Notice how quickly the adenosine reaches the patient.

References

  1. Parker RB, McCollam PL. Adenosine in the episodic treatment of paroxysmal supraventricular tachycardia. Clin Pharm. 1990 Apr;9(4):261-71. PMID: 2184971.
  2. Miyawaki IA, Gomes C, Caporal S Moreira V, et al. The Single-Syringe Versus the Double-Syringe Techniques of Adenosine Administration for Supraventricular Tachycardia: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs. 2023;23(4):341-353. doi:10.1007/s40256-023-00581-w. PMID 37162718
  3. Kotruchin P, Chaiyakhan I, Kamonsri P, et al. Abstract 10470: Comparison between the double-syringe technique and the single-syringe diluted with normal saline technique of adenosine for a termination of supraventricular tachycardia: A pilot, randomized, single-blind controlled trial (DO-single trial). Circulation. 2021;144(Suppl_1). doi:10.1161/circ.144.suppl_1.10470
By |2024-06-19T23:51:46-07:00Jun 24, 2024|Cardiovascular, Tox & Medications, Tricks of the Trade|
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Trick of Trade: Alternative to a Pressure Bag for IV Fluids

pressure bag IV fluidsYou have a severely dehydrated patient with a peripheral IV line, requiring urgent fluid resuscitation. However, the crystalloid fluids are not flowing freely. Multiple attempts were made to place this line with the latest having a flash of blood return and a smoothly flowing saline flush. You can not seem to find your pressure infusion cuff to squeeze the IV bag and accelerate fluid administration.

Trick of the Trade: Manually provide positive pressure fluids using a 3-way stopcock

  1. Attach a 3-way stopcock between the angiocatheter and IV tubing.
  2. In the unused port, attach a 10 or 20 cc syringe.
  3. Fill the syringe with fluids from the IV bag (turn off flow to the angiocatheter using the stopcock)

Trick of the trade stopcock pressure infusion IV fluids syringe start

  1. Rotate the stopcock 180-degrees and push the syringe fluid into the angiocatheter.

Trick of the trade stopcock pressure infusion end

  1. Repeat this process several times.
  2. After manually pushing 100-200 cc of fluid through the line, turn the stopcock to shut off the syringe port. The fluids should flow more rapidly with gravity alone.

Word of Caution: Syringe Fluid Contaminant

Thanks to Twitter feedback from @cpatrick_89, be careful of introducing bacteria when attaching these pieces to the IV tubing, based on an in vitro study. Wearing gloves helped reduce bacterial contamination [1].

Note that conventional pressure bags may not be readily available in emergency departments and could blow the line you worked hard to secure. This “gentle pressure” technique allows the clinician to gauge how much positive pressure to administer to minimize the risk of fluid extravasation.

Interested in Other Tricks of the Trade?

Reference

  1. Kawakami Y, Tagami T. Pumping infusions with a syringe may cause contamination of the fluid in the syringe. Sci Rep. 2021;11(1):15421. Published 2021 Jul 29. doi:10.1038/s41598-021-94740-1
By |2023-07-22T16:33:15-07:00Jul 22, 2023|Cardiovascular, Critical Care/ Resus, Tricks of the Trade|
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Trick of Trade: Dual Foley catheter to control massive epistaxis

Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Initial Management

After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.

Trick of the Trade: Dual Catheter Technique

To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.

dual balloon for massive epistaxis

Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique

Technique

  1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
  2. Inflate the balloon partially with 15-20 cc of air.
  3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
  4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.

For our case, this dual catheter compression technique succeeded in halting the bleed.

Interested in Other Tricks of the Trade?

Reference

  1. Goralnick E. Posterior Epistaxis Nasal Packing. Medscape. Published Dec 9, 2020
By |2023-05-23T23:11:19-07:00May 29, 2023|Genitourinary, Pediatrics, Tricks of the Trade|
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Trick of Trade: Removal of Entrapped Metal Zipper

zipper entrapment injury

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.

Background

The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.

zipper anatomy

Figure 1. Anatomy of a zipper

Penile Entrapment Injury Management Techniques in Literature

Reported techniques for releasing zippers include [1, 2]:

  • Cut the sliding mechanism (aka the endplate) using metal cutters.
  • Use a flat screwdriver placed underneath the sliding mechanism and rotate it.
  • Use mineral oil for lubrication.
  • Use lateral compression technique to relieve the tension on the trapped skin.
  • Cut the zipper and pull the teeth apart.

All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.

The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.

Trick of the Trade: Removing Metal Zippers

Materials Needed

  • Lidocaine gel
  • Blade or scissors

Technique

  1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
  2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
  3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin (Figure 2).
  4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
  5. The remaining parts of the zipper can easily be disengaged from the skin (Figure 3).

metal zipper cut trick zipper entrapment

Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)

metal zipper entrapped free

Figure 3. Freed zipper body

Interested in Other Tricks of the Trade?

References

  1. Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed, Shaw K, Bachur RG (Eds), Lippincott Williams & Wilkins, Philadelphia 2015.
By |2023-05-23T21:20:02-07:00May 24, 2023|Genitourinary, Pediatrics, Tricks of the Trade|
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