Trick of the Trade: Pelvic speculum for peritonsillar abscess

Peritonsillar abscess drainage in the ED continues to be one of my favorite procedures to perform. There are several tricks to increase your chances for a successful aspiration. One trick involves using a curved laryngoscope to help depress the tongue AND provide a bright light source.

What if you don’t have a laryngoscope readily available?

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By Michelle Lin, MD|2019-01-28T23:36:17-08:00Mar 20, 2012|ENT, Tricks of the Trade|

Trick of the Trade: Irrigation fluid is key – but not in your eye!

High pressure irrigation of wounds is critical in reducing the rate of wound infection. There are a variety of commercial irrigation kits which include splash guards. If you are irrigating correctly and generating at least 8 PSI of pressure, some irrigation fluid should splash up and out of the wound. Be careful not to splash irrigation fluid in your eyes.

What if you don’t have a commercial irrigation setup?

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By Michelle Lin, MD|2019-02-19T18:07:59-08:00Mar 13, 2012|Tricks of the Trade|

Trick of the Trade: Another magnet trick for metallic FB removal

Last week, I talked about the use of Rare Earth Magnets for removing metallic foreign bodies. Sometimes a straight magnet though isn’t quite strong enough to grab a metallic foreign body. If only you had a small magnetic hemostat.

This week Dr. Catherine Perry (Culpepper Memorial Hospital) and Dr. Kolapo DaSilva (PGY-2 at UVA) emailed me with a creative solution. They encountered a patient with a BB pellet lodged deeply in the soft tissue. Small mosquito clamps couldn’t get around the BB. A cardiac magnet alone caused the BB to tent the skin up.

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By Michelle Lin, MD|2019-01-28T22:25:49-08:00Mar 6, 2012|Tricks of the Trade|

Trick of the Trade: Rare earth magnets for metallic FB removal

NasalFB

A child presents to your Emergency Department with a small button battery up her nose. Your usual tricks fail:

Occluding the other nostril and having the mother blow in the patient’s mouth forcefully.
Using a small curette or forceps to scoop or pull it out.

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By Michelle Lin, MD|2019-01-28T22:25:39-08:00Feb 28, 2012|Tricks of the Trade|

Trick of the Trade: Difficult intubation — making lemonade out of lemons

In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.

Unfortunately, when you bag the patient, you realize that you are in the esophagus.

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By Michelle Lin, MD|2016-11-11T18:51:16-08:00Jan 31, 2012|Tricks of the Trade|

Trick of the Trade: Minimizing propofol injection pain

“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz…

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection?

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By Michelle Lin, MD|2019-01-28T22:23:58-08:00Jan 24, 2012|Tox & Medications, Tricks of the Trade|

Trick of the Trade: Dental Avulsion and Subluxation

It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground. She’s crying because of the event but is otherwise unscathed. At this point it’s time to take care of the avulsion. What to do?

Trick of the Trade

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

Lightly rinse tooth with saline solution.
Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
Gently reimplant tooth into a satisfactory anatomic position.
Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to the mesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, “mesial” means right edge and “distal” means left edge in dental speak.
Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
Secure the replanted tooth by applying 2-OCA to the inner aspect of the splint and buccal surface of the target and one/both adjacent teeth.
Hold the splint under pressure for about 1 minute.
Confirm stability.

In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.

Warnings

Children: Avulsed primary teeth should not be replanted. Also ensure they will not be at aspiration risk.
Warn the patient that if they feel that the dental splint is loosening, simply remove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.