A patient presents to triage in rapid SVT rhythm. While you are trying to get an IV in the patient and drawing up adenosine, you have the patient perform a Valsalva maneuver to see if increased vagal tone itself will break the arrhythmia. Unfortunately, she is unable to understand your instructions.
A patient re-presents to the Emergency Department with a foreign body sensation in his heel after stepping on a broken window. Despite a negative xray and bedside ultrasound yesterday, the patient still believes that a small foreign body is still in there. You are unable to find a foreign body despite excising the overlying skin with a scalpel and exploring with forceps.
A 3 month old baby presents with distal erythema and swelling of one of her toes. A hair tourniquet is identified. Typically one can try manually unwrapping the tourniquet using forceps, but often only part of the tourniquet can be removed. The distal toe remains swollen and erythematous with delayed capillary refill.
As demonstrated by the image above, it can be difficult to identify the hair because of the edema and the thin nature of the hair (especially if the same as the patient’s skin color). In a 2006 review of hair tourniquets in the Annals of Plastic Surgery, they recommend incising down to the bone along the lateral edge of the digit to ensure tourniquet release. It seems a bit aggressive…
Marking the surface anatomy for procedures can significantly increase your chances for success, such as for lumbar punctures and central lines. I can never seem to find surgical skin markers.
Sometimes classic techniques need to be revisited, especially when I get new photos from the collective readership. Let’s review a painless way to remove beads from the ear canal. You can’t exactly have the patient’s provider blow in the other ear to expulse the bead, similar to a nasal foreign body…
Three weeks ago, I talked about more safely reducing mandibular dislocations. After successful completion of the procedure, how do you make sure that the patient doesn’t re-dislocate the mandible? You definitely should tell the patient to keep their jaw closed as much as possible for the next 24 hours and avoid opening the mouth widely (eg. yawning/laughing).
How do you immobilize the mandible? Especially for the chronic dislocators, presumably with more lax TMJ ligaments, you should think about immobilization. This can be done with a head bandage which goes under the chin. You can use kerlix rolls or an ACE wrap.
You identify a great external jugular (EJ) vein to cannulate for IV access. You are having a hard time keeping the angle of the angiocatheter aimed at a shallow angle because the mandible is in the way. This is typical of patients with chubby necks (eg. pediatric patients) or who are unable to rotate their neck.