Tricks of the trade: Anesthetizing the nasopharyngeal tract
Nasogastric tube placement is one of the most uncomfortable procedures in the Emergency Department. Why can’t we find a painless way to do this? Now that I am doing more fiberoptic nasopharyngoscopes, this issue is coming up more and more frequently. I’ve been using NP scopes mainly to check for laryngeal edema in the setting of angioedema. These recent photos visualize a normal epiglottis and normal laryngeal anatomy, respectively. [+]
Great teaching video: Corneal FB removal
Patients often come into the ED for eye pain. One of my favorite procedures is removal of a small foreign body embedded in the cornea. There is a great instructional video on removing such foreign bodies and the use of a ophthalmic burr on removing rust rings. The video recommends using either a 30-gauge or 18-gauge needle. I prefer the less innocuous-looking 29-gauge insulin/TB needle. Can you imagine someone coming towards your eye with a large 18-gauge needle?! [+]
Paucis Verbis card: Angioedema
Recently, a patient presented with angioedema after starting taking an ACE-inhibitor. There was upper lip swelling, similar appearing to the case above. He also experience a hoarse voice. Before the advent of fiberoptic nasopharyngoscopy, it was assumed that there may be laryngeal edema. Fortunately, using technology, we were able to visualize a normal epiglottis and a grossly normal laryngeal anatomy. Should patient with angioedema be admitted? The 1999 study on admission guidelines, of course, should be weighed with physician judgment and the patient's social issues. The study was retrospective and the results should be weighed carefully. For me, generally I [+]
Trick of the trade: Ear foreign body extraction
A 6-year old boy has placed a hard bead in his ear and presents to the ED for care. How do you remove this foreign body as painlessly as possible? You can just barely see the edge of the bead by just looking at the external ear. By experience, you know that mini-Alligator clips and forceps will not be able to sufficiently grab the edges of the bead. Additionally it may push the bead in even further. [+]
Paucis Verbis card: Knee exam
How accurate is the clinical knee exam? JAMA published a meta-analysis trying to answer this question. Although they include patients with acute and chronic knee pain, it's a good general review of the knee anatomy, historical clues, and exam elements. In the ED, the knee exam is challenging because we see very acute injuries where knee pain and swelling often preclude an accurate exam. For patients with an equivocal exam, be sure to refer for orthopedic follow-up. A repeat exam should be performed once the pain and swelling subside. This installment of the Paucis Verbis (In a Few Words) e-card [+]
Tricks of the trade: Chemical sedation options
You walk into a room where a patient is screaming and thrashing about in his/her gurney from some stimulant abuse. PCP, cocaine, methamphetamine… or all of the above. When the number of people (police officers, security guards, nurses) is greater than the patient’s pupil size, you KNOW that you’ll need some chemical sedation. What intramuscular sedation regimen do you use? [+]
Paucis Verbis card: Hyperkalemia management
Hyperkalemia is a common presentation in the Emergency Department, especially in the setting of acute renal failure. In one shift, I had 4 patients with hyperkalemia! All had from some form of renal failure. This installment of the Paucis Verbis (In a Few Words) e-card series reviews the treatment options for hyperkalemia. PV Card: Hyperkalemia Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Weisberg L. Management of severe hyperkalemia. Crit Care Med. 2008;36(12):3246-3251. [PubMed]
Trick of the Trade: Minimizing abscess odor
Building on my theme of combating odors in the Emergency Department (see Toxic Sock Syndrome), foul-smelling pus from large abscesses has got to be one of the most nauseating smells in the ED for me. Trick of the Trade Use a Yankauer to suction up pus [+]
Paucis Verbis card: Aneurysmal subarachnoid hemorrhage
Atraumatic subarachnoid bleeds are most commonly caused by ruptured intracranial aneurysms. This installment of the Paucis Verbis (In a Few Words) e-card series reviews the current management, knowledge, and challenges in aneurysmal subarachnoid hemorrhage (SAH). PV Card: Subarachnoid Hemorrhage Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Edlow J, Malek A, Ogilvy C. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008;34(3):237-251. [PubMed]
Trick of the trade: Irrigation scalp wound photos
I mentioned from an earlier post about building a "head basin" for collecting irrigation fluid prior to wound closure. This basin prevents a deluge of fluid from soaking the gurney sheets and patient. I finally managed to capture this trick in action, while a student was irrigating an eyebrow laceration. Pearl When cutting out a semi-circular or rectangular hole in the basin, be sure that there remains a 2-4 inch lip at the bottom to ensure that fluid can collect in the basin.
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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