Severe constipation, requiring fecal disimpaction and rectal enemas, can be excruciatingly painful for patients. Administering sedatives and opioids to help alleviate this pain poses a challenge, because many of the patients are elderly and tend to be more sensitive to these medications. Furthermore, there may be increased vagal tone when straining, leading to hypotension and bradycardia and which can result in defecation-related syncope. 1 Also, opioids can exacerbate constipation. Herein we present 2 cases and tricks on achieving better pain control.
The safe placement a central venous catheter (CVC) remains an important part of caring for critically ill patients.1 Over 5 million CVCs are placed each year in the United States. It is crucial to confirm that the central line is placed in the correct position in order to rule out potential complications of the procedure (e.g. pneumothorax) and begin administration of life-saving medications. Post-procedure chest radiographs (CXR) are the standard of care for CVC placements above the diaphragm. However, the annual cost to the U.S. healthcare system for CXRs after CVC placement is estimated to be over $500 million.2 Further, in a busy ED, the limited availability of portable radiography may pose a considerable time delay. Radiography may also be limited in resource‐poor and austere settings, particularly the prehospital and military environments. We review a faster, cheaper, and more accurate alternative for evaluating CVC placement: point of care ultrasound (POCUS).(more…)
A hair tourniquet occurs when a strand of hair coils around a patient’s appendage. It can cause damage to the skin, nerves, or affect blood supply. It is more common in infants as their skin appendages are small which allows for hair or thread to trap inside. Because in some cases these pediatric patients can present with inconsolable crying, it is important to perform a thorough physical examination to evaluate for the presence of such a hair tourniquet. We present a simple trick for removing a hair tourniquet using depilatory cream!
A 25 year-old male presents to the ED complaining of left upper extremity pain, redness, and swelling. His cat bit him 2 days ago and his symptoms started today. On exam he has impressive induration, erythema, and warmth to the dorsum of the hand and forearm. He is neurovascularly intact and able to range his joints freely. In addition to IV antibiotics, you would like to keep his arm elevated while in the hospital. What is an easy and simple way help ensure that this patient keeps his arm elevated?
Penetrating fishhook injuries can be a common occurrence during the warm weather months. Initially, it is important to evaluate what type of fishhook was being used. How many and where are the barbs? What shape is it (treble hook, single hook)? The physical examination requires a thorough neurovascular exam and, if penetration depth is difficult to assess, radiographs should be utilized for further evaluation.
What approach do you use to remove these barbed fishhooks?
A 23-year-old female with no past medical history presents to the ED for the 4th time this month complaining of severe “10-out-of-10” abdominal pain, nausea, and intractable vomiting. She denies alcohol use, but reports she has smoked at least 1 marijuana “bud” daily for the last 3 years. In an attempt to relieve her symptoms, she has increased her marijuana use, however she has found that her pain is actually increasing, and the only thing that appears to help is taking a hot shower or bath. With this statement, the provider immediately considers cannabinoid hyperemesis syndrome (CHS).
A 3 year-old boy presents with a deep laceration of the distal phalanx, through the nail bed, after slamming his fingers in a car door. He is crying, anxious, and uncooperative. How do you make this situation easier to evaluate and repair?
Nail bed and finger laceration repairs can be challenging, and even more challenging in young patients. Preparation is key to getting a good outcome. Here we present a pediatric trick of the trade on immobilizing a finger for digit or nail bed procedures.