Can you imagine trying to bag-valve-mask ventilating this patient without teeth?
Edentulous patients can cause BVM problems because air tends to leak out the sides of the mouth, because the cheeks don’t contact the mask as well. You can do a jaw-thrust and/or place an oropharyngeal airway to help. What else can you do?
Your next ED chart: Finger injury
The finger needs to be anesthetized.
Patient: “I have had this freezing before. The needles really hurt! Is there anything else less painful? “
It is 4 a.m. You pick up a chart. Toe pain.
Thinking this could be an easy injury, you walk over to the patient, only to discover: bilateral ingrown toenails. Your heart sinks. In your head, you are thinking: Lateral nail resection? Nail removal? This could take a while.
Is there a less invasive method for treating an ingrown toenail?
I finally tried the Modified HAT (Hair Apposition Technique) trick for the closure of scalp lacerations. I have used the traditional HAT trick multiple times but not the modified technique.
Instead of using your fingers, the modified approach involves the use of two instrument clamps to help twist and pull the hair strands taut. It turns out that this makes a huge difference, especially for short hairs. The clamps allow you to grab the hair strands so much more securely, before instilling a tissue adhesive at the twisting points.
The nice added benefit was that my chubby fingers were now out of the procedural field. This allowed my assistant to more easily see and reach the hair twisting points with the Dermabond applicator.
Check out the finished product of this 2.5 cm laceration on the scalp vertex.
The simple addition of two instrument clamps provides significantly superior control, stronger tensile strength, and better exposure when twisting hair strands together. Try it.
The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications.
Go to ALiEM (PV) Cards for more resources.
A paracentesis procedure is often performed in the Emergency Department to rule a patient out for spontaneous bacterial peritonitis (SBP).
This installment of the Paucis Verbis (In a Few Words) e-card series provides an evidence-based review of the literature on topics related to the paracentesis procedure. Especially helpful is the pooled data of likelihood ratios. Like most everything in medicine, a lab test should be used in conjunction with your pretest probability in clinical decision making, and LR’s help with with this.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
How do you approach the repair of scalp lacerations in a child? What factors are you considering?
This trick of the trade pearl addresses the stapling technique for scalp laceration repair. Perhaps the child’s hair is too short for the HAT trick.