Digital Otoscope Enhances Decision-Making and Improves Outcomes
Procedural equipment will help you make accurate diagnoses and formulate treatment plans. You want the equipment to work, be readily accessible, and be easy to clean and store. It's also nice when it fits in your pocket.You also want to be sure your staff is trained to use it. Not everyone in your department may want to break out the nasal endoscope for a quick ENT exam, as we discussed last month. (See post below.) But specialized ENT equipment may make your life a bit easier and improve patient outcomes. Using a digital otoscope to view the tympanic membrane is fast, easy, and safe. This particular model costs $24. ...
Source: The Procedural Pause - November 30, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Nasal Endoscopy for Urgent and Complex ED Cases
​Fiberoptics and endoscopy have changed the way we treat patients in the emergency department. Endoscopes are relatively easy to use, and can aid your diagnosis and treatment plan. Endoscopy may be useful in urgent cases, such as epistaxis, nasal foreign bodies, and ear debridement. It may also be helpful when dealing with more complicated presentations and critically ill patients, such as those with Ludwig's angina, epiglottis, tracheostomies, or those who need intubation.Fiberoptic tools are not just for surgeons and consultants. The endoscope has many uses in the emergency department, and we have a few tips and tricks...
Source: The Procedural Pause - October 28, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Cures for Cerumen Impaction
​Cerumen impaction removal may not be considered an emergent procedure in the emergency department, but this omnipresent natural phenomenon will bring patients, from infants to the elderly, to your department at all hours of the day and night because loss of hearing is a foreign and uncomfortable sensation.Cerumen impaction can cause complete hearing loss, pain, dizziness, chronic cough, and even infection. Patients who attempt to remove cerumen at home can end up with otitis externa or otitis media and even tympanic membrane trauma. The cerumen can block visualization of the tympanic membrane so TM rupture or ear infect...
Source: The Procedural Pause - October 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Fishing Out the Fish Hook
​Outdoor recreation has exploded since we all began social distancing for COVID-19, and EDs are seeing more camping and home improvement injuries from table saws, crafting projects, and even canning (burns). Boating and motorcycle accidents also seem to be on the rise. Many fisherfolk will be on and in the water using hooks, barbs, lines, and wires. Many of these anglers will arrive with a hook in the arm, hand, or scalp, unable to remove the hook themselves. In fact, their own attempts to remove the hooks may make matters worse. Fish hook injuries may seem simple at first, but can quickly get complicated, depending on t...
Source: The Procedural Pause - September 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Quigley Maneuver for Ankle Fractures
​Certain emergency department procedures bring us a sense of accomplishment. We cheer after a shoulder returns to its correct position from our relocation technique and smile when a laceration closes just right. Emergency department procedures can be very rewarding for providers and patients, especially during times of stress in the workplace. Sometimes, just stapling a scalp or molding the perfect splint may seem cathartic. There are days where we can only see so much abdominal and chest pain—and COVID-19.The double-person Quigley maneuver technique for an ankle fracture. Photo by Martha Roberts.This month we want to ...
Source: The Procedural Pause - August 3, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

One-Stop Pain Control for Trimalleolar Fractures
​The incidence of all ankle fractures is about 187 cases per 100,000 people each year. Trimalleolar fractures occur in seven to 11 percent of those cases. (Orthop J Sports Med. 2019;7[11 Suppl 6]; https://bit.ly/3eQ4lRl.) Trimalleolar fractures involve the lateral and medial malleolus and the distal posterior aspect of the tibia (sometimes called the posterior malleolus).These fractures are serious and often unstable. They typically but not always need urgent or even emergent surgery. Often, they are reduced with a closed reduction prior to surgery. We suggest using a hematoma block to assist with pain control during...
Source: The Procedural Pause - July 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Resolve Otitis Externa Fast with an Ear Wick
​Emergency providers expeditiously sift and sort patients on their shifts and streamline procedures like how to place an ear wick in a patient with otitis externa, a quick and useful procedure for a patient who will reap the rewards.Standard ear wicks. The material is made from a dehydrated sponge composed of hydroxylated poly(vinyl acetate). It increases in size when liquid is applied. Photo by M. Roberts.Otitis externa can cause significant swelling, irritation, pruritis, and pain to the ear canal. Occasionally, the canal is so swollen it may be difficult to administer ear drops. An ear wick can be inserted between the...
Source: The Procedural Pause - June 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Part Two: Mastering Wrist Arthrocentesis
​We discussed the initial approach to the red, hot swollen wrist joint last month, and this month we focus on arthrocentesis of the joint with a full video of the procedure, including ultrasound and joint aspiration.A swollen, painful wrist that is hot to the touch with scant erythema is concerning for septic arthritis. The patient had multiple Band-Aids on his fingertips from blood glucose testing for diabetes, which increased his chances of having a septic joint with the punctures serving as an entry site for infection. Photo by Martha Roberts.The ProcedureIdentify the swollen joint, review the differential diagnosis, ...
Source: The Procedural Pause - May 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Part One: Tapping the Wrist
​The wrist is not commonly aspirated in the emergency department, but emergent arthrocentesis may be indicated for extreme or concerning cases, and tapping the wrist to determine the underlying pathology or relieve pain may be of great value. The synovial fluid from the joint space can be analyzed for crystals, infection, and blood. This information may help determine the overall plan and aid in decision-making and consultation. The ultimate treatment plan may include admission, intravenous antibiotics, multiple aspirations, and even surgical washout.A swollen, painful wrist that is hot to the touch is concerning for sep...
Source: The Procedural Pause - April 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Paracentesis: The Procedure
Discussion: The Z-track method minimizes fluid leakage from the puncture site. Injecting medication into the skin using this method is important to preventing post-procedure leaking. Once a needle has entered subcutaneous tissue and muscle, it opens a track that may not reseal immediately. There are also studies suggesting that Z tracks may reduce pain during injection. We suggest using the method during your paracentesis procedure.Z tracks are used for all kinds of intramuscular injections and can be applied to other sites on the body. Pull and press the skin and tissue 2 cm caudad to the deep abdominal wall and inser...
Source: The Procedural Pause - March 3, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Using Ultrasound for Paracentesis
​Paracentesis can be a quick and simple procedure with the right equipment and a well-rehearsed approach. It's important to practice this skill in the procedure lab and to familiarize yourself with the kit in your department a few times a year. This month, we focus on paracentesis set-up and basics, and next month we will review the nuts and bolts of completing the procedure.Important equipment for paracentesis: Five or six collection bottles, antiseptic prep, and a paracentesis kit. Consider longer needles for abdominal walls thicker than 2.5 cm.Grab the ultrasound and a pen. Position your patient at a 45-degree ang...
Source: The Procedural Pause - February 3, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Ride the Fluid Wave Before Performing a Paracentesis
​Before you break out the bottles for a paracentesis, you may want to consider doing a test for ascites. Many procedures require executing an old-school test before even looking at a result or grabbing an ultrasound machine. Knowing what to look for on a physical exam may guide your practice and intervention dramatically. Using noninvasive tools first could help your patient avoid other tedious or unnecessary testing, which may also result in lost time. Incorporating ultrasound into your practice may also help you nail a diagnosis or allow you to perform a procedure better than you expected.A markedly distended abdomen d...
Source: The Procedural Pause - January 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Treating Fingertip Amputations
​Fingertip injuries and amputations are common in the emergency department, often occurring on weekends when consultants are not available. Some experienced physicians may consider rongeuring distal tuft amputation injuries, but simple closure and expert consultation for more difficult cases are suggested.A fingertip amputation within zone III involving total amputation of the distal tip, fingernail, matrix, and tuft. Photos by M. Roberts.Care of fingertip amputations in the ED should focus on removing debris and cleaning the wound as best as possible, closing the wound using available skin, bandaging and splinting for c...
Source: The Procedural Pause - December 5, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Evacuating the Nefarious Subungual Hematomas
​Subungual hematomas can be a terror. They are painful, ugly-looking, nefarious, and sometimes confusing. The ultimate goal is to drain the accumulated blood and relieve the painful pressure.The best intervention is easy and straightforward: Leave the nail in place, and evacuate the blood under it. (Hand Surg. 2012;17[1]:151; Am J Emerg Med. 2006;24[7]:875; Emerg Med J. 2003;20[1]:65, http://bit.ly/2mHV1cO.) Then, provide excellent discharge information without prescribing antibiotics.A subungual hematoma in a 21-year-old man who slammed his thumb in a car door about 12 hours before ED arrival. Photo ...
Source: The Procedural Pause - November 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Figure-of-Eight Sutures for Bleeding Varicose Veins
​The figure-of-eight suture is a fascinating technique, often used in unique cases. The stitch is extremely secure and easy to place. It can be used to save time during long, complicated repairs and to create additional strength in high-tension areas. The figure-of-eight stitch can be modified to bring skin edges together or close off small bleeding arteries, varicose veins, or even bleeding hemorrhoids. Multiple figure-of-eight sutures can be used in a row.The idea is to use a single suture to surround a small area of tissue in a box shape to close a laceration or put pressure on a small site. Figure-of-eight sutures ca...
Source: The Procedural Pause - October 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs