Trick of the Trade: A Fast Exit Strategy for the TACO Method in Heat Stroke Resuscitation

TACO heat stroke cooling exit: tilted hospital bed draining ice from a body bag into a trash bin

An unidentified male presents to the emergency department via ambulance after being found unresponsive in the heat. His initial rectal temperature is 108°F (42.2°C), and his GCS is 4 for nondescript groaning. The team quickly secures the airway and places a temperature-sensing urinary catheter while ice arrives from the cafeteria. They start rapid cooling, the cornerstone of heat stroke management, with the Tarp-Assisted Cooling with Oscillation (TACO) method and reach 102°F (38.9°C) quickly [1,2]. After a brief sigh of relief, another problem arises: how do you rapidly stop the cooling process to avoid overshooting into hypothermia?

The team now faces several logistical challenges in this common but time-sensitive scenario, including the management of multiple points of unwieldy but critical tubing while moving the patient, minimizing spillage of contaminated water, and, most importantly, preventing hypothermia. Most cooling protocols focus on how to start cooling by immersion, and not so much on how to end it. Our quick and simple trick adds one vital tool: gravity.

Trick of the Trade

Tilt the bed foot-down, cut open the foot of the body bag, and let gravity drain the ice-water slurry into a trash bin.

Materials

Disposable body bag, used as the TACO immersion vessel
Large trash bin
Trauma shears
Towels

Steps

Perform TACO in a disposable body bag. While cooling is underway, place a large trash bin at the foot of the bed.
Once core temperature reaches 102°F (38.9°C), raise the bed to maximum height.
Place the bed in reverse Trendelenburg, so the foot of the bed tilts down.
Use trauma shears to cut across the foot of the body bag. Be careful of the patient’s toes!
Have the team push the ice-water slurry into the bin, with gravity to assist.
When most of the ice water is in the bin, towel-dry the patient.

In our case, the patient was dry in less than 2 minutes and never became hypothermic. The team could then remove the body bag and reposition the patient safely, without the time pressure.

Tips

Time-saving maneuver: if the patient needs an airway before cooling, place the temperature-sensing urinary catheter while intubation is underway.
Continuous core temperature monitoring allows early recognition of when to stop active cooling.
Reverse Trendelenburg lets gravity assist with rapid evacuation. This buys time later to reposition the patient carefully and avoid accidental removal of critical lines and tubes.

Read more from the Tricks of the Trade series.

References

Luhring KE, Butts CL, Smith CR, et al. Cooling effectiveness of a modified cold-water immersion method after exercise-induced hyperthermia. J Athl Train. 2016;51(11):946-951. doi: 10.4085/1062-6050-51.12.07
Comp G, Pugsley P, Sklar D, et al. Heat stroke management updates: a description of the development of a novel in-emergency department cold-water immersion protocol and guide for implementation. Ann Emerg Med. 2025;85(1):43-52. doi: 10.1016/j.annemergmed.2024.07.013

By Abigail Riley, BS|2026-09-22T23:25:02-07:00Sep 23, 2026|Critical Care/ Resus, Environmental, Tricks of the Trade|

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

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
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 Lourdina Payen, BS|2026-08-16T07:48:13-07:00Aug 16, 2026|Orthopedic, Tricks of the Trade|

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:

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

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 Jibreel Abdul Cader, BS|2026-03-11T14:06:47-07:00Mar 18, 2026|Trauma, Tricks of the Trade|

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.

Clamp the IV tubing just upstream from the injection port and cut off all the unused upstream IV tubing.
Attach a 10 cc syringe with local anesthetic to the injection port.
Attach the other end of this IV tubing (Luer lock attachment) to the procedural needle.
Prime the IV line with the anesthetic.
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 Chirag Parikh, DO|2024-10-23T07:23:46-07:00Oct 23, 2024|Neurology, Tricks of the Trade, Ultrasound|

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].

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

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

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

Parker RB, McCollam PL. Adenosine in the episodic treatment of paroxysmal supraventricular tachycardia. Clin Pharm. 1990 Apr;9(4):261-71. PMID: 2184971.
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
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 Mike Olshansky, DO, RN|2024-06-19T23:51:46-07:00Jun 24, 2024|Cardiovascular, Tox & Medications, Tricks of the Trade|

Trick of Trade: Alternative to a Pressure Bag for IV Fluids

pressure bag IV fluids You 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

Attach a 3-way stopcock between the angiocatheter and IV tubing.
In the unused port, attach a 10 or 20 cc syringe.
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

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

Trick of the trade stopcock pressure infusion end

Repeat this process several times.
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

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 Michael Cataldo, DO|2023-07-22T16:33:15-07:00Jul 22, 2023|Cardiovascular, Critical Care/ Resus, Tricks of the Trade|

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.

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

Technique

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.
Inflate the balloon partially with 15-20 cc of air.
Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
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.