Trick of the Trade: Persistent Paracentesis Leakage 2.0

Paracentesis leakage

You’re seeing a patient returning to the ED after a recent diagnostic paracentesis. The patient is complaining of persistent peritoneal fluid leakage. They’ve tried putting pressure with no success. You tried applying a medical adhesive glue and noticed it was unsuccessful, based on the patient’s gown continuing to get wet with ascites fluid. Now what?

Trick of the Trade: Pressure Gauze and Transparent Film Dressing  

The medical adhesive glue trick was proposed in the Trick of the Trade 1.0 version by Dr. Borloz and Dr. Lin in November 2012. 

Materials Needed

MaterialQuantity
Benzoin tincture1
Gauze 2″ x 2″1-2
Transparent Film Dressing (Tegaderm) 2.5″ x 2.75″3-4

Technique

1. Apply benzoin tincture surrounding the area of the leakage.
gauze ball in hand
2. Use a 2″ x 2″ gauze and roll it into a tight round ball. Hold the gauze with firm pressure over the leak (it is easier if you have the patient or an assistant holding it in place while you move on to the next step).
4. Stretch the transparent film dressing before placing it over the center of the gauze
4. Continue to hold firm pressure on the gauze from over thetransparent film dressing. Note that you are not yet touching the dressing against the skin.
5. Stretch outtransparent film dressing and affix to the patient’s skin.
6. Once you apply the initial transparent film dressing, you can apply 2-3 more over the top, in the same fashion, to increase the pressure on and security of the dressing. Patients may be discharged with this dressing in place for 24-48 hours.

Pro Tip

Consider combining both this trick of the trade and the adhesive glue technique. Hat tip to Dr. Christian Rose [Twitter @RoseLikeTheFlwr] for this idea. 

Interested in other Tricks of the Trade posts?

Read the series of Tricks of the Trade posts.

By |2021-10-15T12:48:11-07:00Oct 20, 2021|Gastrointestinal, Tricks of the Trade|

Trick of the Trade: Tibial Intraosseous Line Stabilization in an Agitated Patient

Intraosseous needle - image from Dr. Rob CooneyWith the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made much easier. Securing the IO needle to the patient’s tibia, femur, or humerus, however, is a different story. After successful patient resuscitation, these needles often tenuously secured through creative uses of sterile gauze, trimmed paper cups, bag valve masks, and/or just tape. Stabilization of tibial IO lines can be difficult in a sedated, intubated patient. This can be even more difficult in an agitated, moving patient.

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By |2020-01-16T00:17:39-08:00Jul 20, 2016|Critical Care/ Resus, Tricks of the Trade|

Simulation Trick of the Trade: Bleeding Cricothyroidotomy Model

One advantage of simulation as an educational tool is the re-creation of cognitive and emotional stresses in caring for patients. Doing this for a high fidelity scenario is relatively easy – add additional patients, make a them loud, combative, or otherwise cantankerous, and add interruptions for good measure. However, when training for procedures in the simulation lab, we practice the procedure in isolation on a “task trainer” without cognitive and emotional stress for context. An off-the-shelf task trainer can do a superb job of teaching the mechanics of performing a procedure, but they lack complexity necessary to train for performing the procedure under stress. (more…)

Trick of the Trade: EMLA for Lumbar Punctures

LP_collect copyA 9 year-old patient presents with a headache and fever after swimming, along with subjective neck stiffness. Meningitis was of concern especially because the serum WBC count was 25,000 and other inflammatory markers were elevated. Because the patient’s mother had an unpleasant experience with an epidural during childbirth, she adamantly opposed the idea of a lumbar puncture (LP). 

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By |2016-11-11T19:03:55-08:00Sep 26, 2013|Tricks of the Trade|

Ultrasound-Guided Pericardiocentesis

pericardial tamponade ultrasound pericardiocentesis

All the years of ultrasound training in residency has paid off. You found the large pericardial effusion in the hypotensive patient who is still alive, but looks sick. You are a star! The only problem was that you never performed a pericardiocentesis in an awake patient. The cardiology fellow is at home sleeping and/or the closest receiving hospital is about 1 hour away. Now what?

Dr. Arun Nagdev reviews how to do an ultrasound guided pericardiocentesis as part of this new, ongoing series of advanced ultrasound tips for emergency physicians.

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By |2019-08-17T12:49:52-07:00Aug 22, 2013|Cardiovascular, Ultrasound|

Trick of the Trade: The PIPP for deep peripheral IVs in obese patients

SVT_Lead_II-2The Case

A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with a rate of 160 bpm. His BP is in the 130s systolic, and he is otherwise stable. You know you have a bit of time. Meanwhile, the nurses begin searching for veins to start an IV… 

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By |2016-11-11T19:02:44-08:00Aug 5, 2013|Tricks of the Trade, Ultrasound|

Trick of the Trade: Less traumatic nasopharyngoscopy


ViscousLidoNosesm
A fiberoptic nasopharyngoscope is a handy tool to check patients for suspected foreign bodies (e.g. fishbone stuck in throat) or laryngeal edema. Depending on the diameter of your fiberoptic cable, it may be fairly uncomfortable for the patient despite generous viscous lidocaine instillation through the nares and nebulized lidocaine. Alternatively or additionally, you can make your own lidocaine-oxymetazoline nasal atomizer which works well.  

What if the patient is STILL not tolerating the procedure well? 

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By |2016-11-11T19:02:31-08:00Jul 16, 2013|ENT, Tricks of the Trade|
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