A patient’s PICC line becomes obstructed and presents to your ED for care. She is using it for chronic antibiotics for osteomyelitis. You are unable to aspirate and flush it with saline using a 10 cc syringe.

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Last week, Dr. David Johnson shared his trick to elicit a Valsalva maneuver out of his patient. Here’s another trick that I saw one of our EM residents use in an attempt to break a SVT rhythm.

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.

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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…
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 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.