The Dirty Epi Drip: IV Epinephrine When You Need It

PeanutAllergyBraceletYou’re a recent graduate picking up an extra shift in a small ED somewhere north of here. At 3 AM an obese 47 year-old woman presents with shortness of breath and difficulty speaking after eating a Snickers bar an hour earlier. She admits to history of hypertension, peanut allergy, and a prior intubation for a similar presentation. She is becoming more obtunded in the resuscitation room as you are collecting your history. A glance at the monitor shows:

  • HR 130
  • BP 68/40
  • O2 saturation 89% on room air

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Trick of the Trade: Got a shoulder dislocation? Park it

ShoulderDLxray

Myriad techniques exist to reduce shoulder dislocations, which includes scapular rotation, Hennepin, Snowbird, Cunningham, and Legg maneuvers. They are nicely reviewed at ShoulderDoc.co.uk. You can also supplement any technique with ultrasound-guided intraarticular lidocaine for improved pain control.

Recently, Dr. Jay Park (Beth Israel Medical Center in New York) contacted me about his novel approach to shoulder reduction which anatomically makes sense. If his animation video doesn’t convince you, check out the video of an actual reduction.

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By |2019-01-28T21:59:02-08:00Jun 25, 2013|Orthopedic, Tricks of the Trade|

Trick of the Trade: Making the NG and NP procedures less painful

When doing nasogastric (NG) tubes and fiberoptic nasopharyngoscopy (NP) procedures, there many approaches in how patients can be locally anesthetized. Getting things pushed up your nose is so profoundly irritating that most patients only give you 1 or 2 changes to get it right.

One option is to use nebulized lidocaine, although it takes a while to prepare and anecdotally tends to numb mainly the hypopharynx, placing the patient at risk for aspiration later on. Another option is to use viscous lidocaine to coat the NG or NP tubing, but this is fairly messy and only mildly helpful. Commercial intranasal atomizers, which disperse lidocaine over the nasal mucosal surfaces well, are generally effective, but may not be available in some emergency departments.

By |2019-02-22T13:34:02-08:00Apr 23, 2013|Tricks of the Trade|

Trick of the Trade: Rapid Oral Phenytoin Loading in the ED

A 57 y/o, 75 kg male presents to the ED after a witnessed seizure. He describes a history of seizure disorder and is prescribed phenytoin, but recently ran out. A level is sent and, not surprisingly, results as < 3 mcg/mL (negative). After a complete ED workup, the decision is made to ‘load’ him with phenytoin 1 gm and discharge him with a prescription to resume phenytoin. An IV was not placed.

Can you rapidly load him orally?

Trick of the Trade: No pelvic bed? No problem

Pelvic SpeculumOften finding a pelvic examination bed for a female patient needing a speculum exam can be challenging. Without the elevated foot stirrups, the bed under the patient’s buttocks obstructs the pelvic speculum handle so that it can’t rotate completely into a 6 o’clock position.
Some people place an upside-down bed pan to elevate the patient’s buttocks slightly in order to create more space for the speculum. Not only is the position uncomfortable for the patient, it seems a waste of a perfectly good bed pan. Fortunately there is an alternative approach.
By |2019-01-28T22:00:26-08:00Mar 26, 2013|Ob/Gyn, Tricks of the Trade|