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Trick of the Trade: Stabilizing mandibular relocations

MandibleBandage-1

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.

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By |2021-01-01T23:08:28-08:00May 15, 2012|ENT, Tricks of the Trade|
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Trick of the Trade: Seldinger chest tube technique using bougie

HemoPTXA 40 year-old man presents with a traumatic hemopneumothorax. He weighs 400 pounds.

Chest tubes can sometimes be challenge, especially for those with extra redundant tissue to tunnel through before reaching the intrathoracic cavity. You want to avoid placing the chest tube mistakenly in the subcutaneous space. How can you ensure that your chest tube actually reaches the intrathoracic space?

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By |2019-01-28T22:18:57-08:00May 1, 2012|Social Media & Tech, Tricks of the Trade|
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Trick of the Trade: Protecting your thumbs in mandible relocations

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Does anyone think that this is generally a bad idea when closed-reducing mandible dislocations? Yes, it’s easiest to apply downward pressure on the mandible by pushing down on the occlusal surfaces of the molar teeth. Sometimes, however, when the mandible relocates into place, the teeth clamp shut abruptly – placing your thumbs at risk. How can you prevent any injuries to yourself?

One way is to slide gauze into the mouth during your procedure. Start the video around the 1:30 mark for an exam.

 

Trick of the Trade: Mandible Relocations

Apply a protective roll of gauze over each thumb. Additionally, you can wear a second glove to cover the gauze. No, those are NOT just fat thumbs under the gloves.

ThumbWraps1

ThumbWraps2 Thanks to Dr. Liz Brown (UCSF-SFGH EM resident) for the trick!

 
By |2016-11-11T18:45:03-08:00Apr 24, 2012|ENT, Tricks of the Trade|
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Trick of the Trade: Peritonsillar abscess aspiration technique using IV tubing

peritonsillar abscess aspirationA few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion. An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter.

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By |2024-10-22T15:42:12-07:00Apr 17, 2012|ENT, Tricks of the Trade|
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Trick of the Trade: Urine pregnancy test without urine

pregnancy_tests_in_bulk
A 25 year old woman presents to the Emergency Department having syncopized in the waiting room, where she was triaged with the chief complaint of abdominal pain. Ectopic pregnancy immediately bubbles to the top of your differential diagnosis. The patient is too dizzy to walk to the bathroom to give you a urine specimen to check a urine pregnancy test. Plus, she admits that she just urinated in the waiting room bathroom a few minutes ago – so no urine now.

Trick of the Trade

Apply several drops of whole blood (instead of urine) into the pregnancy test cassette. In the photo below, the patient was pregnant with a serum beta-HCG level of 250 mIU/mL whose urine and whole blood qualitative tests were both positive.

PregWholeBood

Did you know that most urine pregnancy test kits are approved for both urine and serum samples? On a quick Google search, I found that Accutest, Cardinal Health, ICON, OSOM, and Rapid Response all are approved for both. The question is whether this will work for whole blood.

One study 1 in the Journal of Emergency Medicine by Dr. Fromm from Maimonides Medical Center looked at exactly this issue. Whole blood pregnancy test performed extremely well, especially if positive:

  • Sensitivity 95.8%
  • Specificity 100%
  • Negative predictive value 97.9%
  • Positive predictive value 100%

In their study, very low beta-HCG values (<159 mIU/mL) occasionally yielded a false negative for whole blood pregnancy tests. The whole blood testing approach missed a total 9 of 425 pregnancies. Interestingly, the urine pregnancy test was also negative in 5 of those 9 and not performed in the other 4.

Bottom Line

Believe a positive test. Confirm all tests with a urine qualitative test or quantitative serum beta-HCG.

Tip

  1. Be sure to wait at least 5 minutes when using whole blood in the kit. It sometimes takes a while.
  2. Do not apply additional drops of water or saline to the whole blood sample. This causes unnecessary dilution. Just wait for the blood to osmose across the entire test strip.
  3. This is trick is ONLY for medical professionals and not the lay public. We are discussing an actual blood draw and not a simple cut on a finger to obtain blood.

Another example courtesy of Dr. Joe Habboushe (New York Hospital–Queens of Cornell University) and Dr. Graham Walker (Stanford) 2 :

Pregnancy1
Time: 1 minute
Pregnancy2
Time: 5 minutes

S = Sample well; T = Test specific (will show bar if +HCG); C = Control (will always have a bar)

 

References

  1. Fromm C, Likourezos A, Haines L, Khan A, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012;43(3):478-482. [PubMed]
  2. Habboushe J, Walker G. Novel use of a urine pregnancy test using whole blood. Am J Emerg Med. 2011;29(7):840.e3-4. [PubMed]
By |2020-12-04T13:15:41-08:00Apr 10, 2012|Expert Peer Reviewed (Clinical), Ob/Gyn, Tricks of the Trade|
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Trick of the Trade: Fluorescein eyedrops

FluoresceinStrip
This is a guest post by Dr. Ian Brown (Stanford):

The Roberts textbook describes the procedure of corneal fluorescein staining as touching a moistened fluorescein strip to the cornea.  Maybe it is an irrational fear of a paper cut to the sclera, or a fear of touching an already abraded cornea with the paper, but I try to find an alternative. I have seen physicians hold the eye open with one hand, hold the fluorescein with a second hand and then drip tetracaine on the paper and let it drip into the eye with a third hand. I, unfortunately, only have two hands.
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By |2019-01-28T23:36:28-08:00Mar 27, 2012|Ophthalmology, Tricks of the Trade|
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