Bedside Procedures that Will Enrich Your Practice

George L. Higgins III, MD, FACEP Emeritus Professor of Emergency Medicine Maine Medical Center Tufts University School of Medicine Objectives

•Review a number of easily performed and mastered bedside procedures that will benefit your patients

•Briefly describe the conditions warranting these procedures as well as the potential complications of the procedure to consider

•Share our collective experience Our Time Together

•This will not be an exhaustive review of all possible acute care procedures

•We will not discuss nerve blocks, but I encourage you to master these

•For example, Fascia Iliaca Blocks can be used effectively and safely to manage hip fracture pain in elderly patients Our Time Together

DISCLOSURES

NONE Our Time Together

A Head to Toe Adventure Life-threatening Scalp Laceration Hemorrhage Bleeding Scalp Laceration

 Can result in life-threatening hemorrhage

 Traditional suturing can be time consuming and potentially dangerous for the provider in the hectic resuscitative environment

 Cosmesis is usually not the top priority at that moment Bleeding Scalp Laceration

 When control of hemorrhage is a top priority…

 Apply direct pressure to the most actively bleeding areas  Clean debris to the best of your ability  Determine the presence or absence of an obvious underlying skull fracture  Including depressed fragments  Check for open fractures with exuding brain  Use local lidocaine with epinephrine if time allows  Not required in the obtunded patient  Move immediately on to definitive hemorrhage control Bleeding Scalp Laceration

 Step 1: Control hemorrhage rapidly, ideally with Raney Clips

 Step 2: Quickly close the laceration with staples  Faster and less costly  Similar healing times, infection rates and cosmetic outcomes Raney Clips Stapling Technique

 Evert edges of the laceration with forceps or thumb and finger  Align the center of the mark on the staple with the center of the wound  Firmly place the staples, but avoid indenting the skin  Remove them in 10-14 days using the tool designed for removal

 A quick back-up procedure: the modified Hair Opposition Technique Stapling Technique Hair Opposition Technique

Getting at the Scalp Wound Without a Razor

Apply Antibiotic Ointment to Keep Hair Out of the Surgical Field Life-threatening Scalp Laceration Hemorrhage

You can quickly control life-threatening hemorrhage with staples +/- Raney Clips Occipital Neuralgia aka Cervicogenic Headache Occipital Neuralgia aka Cervicogenic Headache

 The trigeminocervical nucleus  A region where the trigeminal nerve fibers intersect with the ascending fibers of the upper cervical roots

 Pain localized to the upper neck and occipital (nuchal) ridge

 Described as paroxysmal, sharp, knife-like, piercing, sudden, unbearable, lightning-like, shock-like, electric Occipital Neuralgia aka Cervicogenic Headache Occipital Neuralgia aka Cervicogenic Headache

 Physical Exam:  Normal neurological exam  Myofascial trigger-point tenderness over the occipital ridge which duplicates the pain syndrome  Usually unilateral, but can be bilateral  No evidence of Herpetic zoster Occipital Neuralgia aka Cervicogenic Headache

 Treatment in the acute phase of management is local nerve block

 Identify the maximal point of tenderness  Usually located over the occipital (nuchal) ridge  Clean the area vigorously  Inject a reasonable combination of long- acting anesthetic and regional steroid  E.g 2-3cc of 0.5% bupivacaine and 20-40mg of depo-methylprednisolone Occipital Neuralgia aka Cervicogenic Headache

Inject at Point of Maximal Tenderness Occipital Neuralgia aka Cervicogenic Headache

Look for It Treat It Your Patients will be Thankful Vertigo: The HINTS Exam VERTIGO: What Is It?

 A symptom of illusory movement  Perceived self-motion  Perceived motion of the environment

 We all experienced this as children VERTIGO: What Organs Sense Motion?

Your First Essential Binary Question: Is It Peripheral or Central? VERTIGO: Multiple Binary Decisions

VERTIGO The most critical decision

PERIPHERAL CENTRAL UNCERTAIN VERTIGO: Multiple Binary Decisions

A clear VERTIGO diagnostic path

CENTRAL UNCERTAIN

NEUROIMAGING

HINTS Essential Bedside Tests

 Head Impulse test

 Nystagmus

 T est of Skew

Stroke 2009;40:3504 Ann Emerg Med 2014;64:265 Head Impulse Test

Watch for a Corrective Saccade

NEJM 2003;348:1027

Head Impulse Test

 Use it to differentiate vestibular neuritis from central vertigo  Not a BPPV test  Patients need to be persistently symptomatic

 A positive test = peripheral vertigo (not intuitive!!)  Vestibular nerve dysfunction NYSTAGMUS

Good Nystagmus: horizontal, unidirectional

Bad Nystagmus: vertical, rotatory, bidirectional SKEW DEVIATION; ANOTHER CENTRAL CLUE

Have the patient focus on your nose. Rapidly alternate covering each eye. Watch for a corrective saccade. A positive test = central vertigo!

Neurology 2012;79:e146 The HINTS Exam: Master It! Dix Hallpike & Epley Maneuvers for Otolithic Peripheral Vertigo VERTIGO: Dix-Hallpike Maneuver

 Performed to provoke symptoms in an asymptomatic patient with a history consistent with vertigo

 It is not required in symptomatic patients  And they will never forgive you if you do make they even more symptomatic VERTIGO: Dix-Hallpike Maneuver

 Head is turned to one side and lowered over the edge of the stretcher

 Symptoms and nystagmus may develop within several seconds and improve in about 30 seconds

 If not, repeat the procedure with the head turned to the other side BPPV VERTIGO: Dix-Hallpike Maneuver VERTIGO: Dix-Hallpike Maneuver

 A well performed D-H maneuver that produces no symptoms suggests spontaneous resolution of BPPV

 A positive D-H maneuver is consistent with BPPV  I don’t repeat if because I’ll move on to the Epley maneuver BPPV VERTIGO: Dix-Hallpike Maneuver Epley Maneuver for Otolithic Peripheral Vertigo

The Epley Maneuver is performed to move obstructing otoliths back into a non-obstructing position Epley Maneuver for Otolithic Peripheral Vertigo

 Sit patient upright and turn head 45° toward affected side D- H provoked side or side that provokes nystagmus

 Keep head in this position and assume supine position with 30° neck extension  1- 2 minutes or until vertigo resolves

 Turn head 90° in opposite direction  1- 2 minutes or until vertigo resolves)

 Then… Epley Maneuver for Otolithic Peripheral Vertigo

 Turn up on side with nose pointing toward floor  1- 2 minutes or until vertigo resolves

 Sit up with head still turned  1- 2 minutes or until vertigo resolves

 Repeat 2 additional times as needed

Epley Maneuver for Otolithic Peripheral Vertigo Epley Maneuver for Otolithic Peripheral Vertigo Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy

 An ocular emergency

 The retina and optic nerves tolerate ischemia for only 1-2 hours

 Multiple cause:  Trauma  Coagulopathy: e.g. Hemophilia  Orbital cellulitis  Etc. Orbital Compartment Syndrome & Lateral Canthotomy

 Symptoms and signs:  Pain  Decreased vision  Diplopia  Proptosis  Intra -ocular pressure > 40mmHg

 Why?  The medial and lateral canthal tendons anchor the eyelids to the orbital rim and inhibit anterior decompression of the globe Orbital Compartment Syndrome & Lateral Canthotomy

The Canthal Tendon Anatomy Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy

Consider placing a Morgan Lens to protect the globe. Administer topical anesthetic in the awake patient. Orbital Compartment Syndrome & Lateral Canthotomy

Have an assistant provide improved exposure using retractors. Orbital Compartment Syndrome & Lateral Canthotomy

 The procedure:

 Anesthetize with 1-2% lidocaine with epinephrine  Direct toward and to the lateral orbital rim

 Using a straight hemostat, crimp the lateral canthus to the orbital rim for 2-3 minutes

 Using iris scissors, bisect the canthus all the way to the orbital rim Orbital Compartment Syndrome & Lateral Canthotomy

 The procedure:

 Retract the inferior eyelid and dissect out the inferior crux of the lateral canthal ligament, using the hemostat  Dissect infero-laterally to avoid globe injury

 Bisect the inferior crux of the lateral canthal tendon with the scissors

 If no improvement, repeat the procedure for the superior crux of the lateral canthal tendon Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy Orbital Compartment Syndrome & Lateral Canthotomy

 Evidence of success  Return of vision  Normalization of intra-orbital pressure  10 -20mmHg

 Main complication to avoid:  Iatrogenic globe rupture

 Absolute contra-indication to the procedure:  Pre -existing globe rupture Orbital Compartment Syndrome & Lateral Canthotomy Tissue Adhesive Near the Eye Tissue Adhesive Near the Eye

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Accidental Instillation of Tissue Adhesive = Into the Eye Can Cause Exothermic Corneal Burns Tissue Adhesive Near the Eye Tissue Adhesive Near the Eye

Before Removing the Backing from Tegaderm, Cut an Opening the Size of the Laceration Tissue Adhesive Near the Eye

Remove the Backing and Position the Covering, Ensuring Firm Contact Tissue Adhesive Near the Eye But what do you do if your accidently glue the eyelids together? Answer: Petroleum based antibiotic ointment

(Example E.g.: erythromycin ophthamic ointment) Tissue Adhesive Near the Eye

Voila! Noninvasive Removal of Nasal Foreign Bodies Nasal FB Removal

 Lots of techniques described

 Foley catheter  Fogarty catheter  Ear curette  Suction catheter  Tissue adhesive/Q-tip  Bayonet forceps Nasal FB Removal

 Positive pressure is a relatively noninvasive and effective technique

 Less risk of iatrogenic harm

 Parent Kiss  Provider Kiss  Ambu Bag Kiss  Positive Pressure Gas Flow Noninvasive Removal of Nasal Foreign Bodies

Parent Kiss Ambu Kiss Bob’s favorite: The Fogarty Catheter Noninvasive Removal of Nasal Foreign Bodies

Positive Pressure Gas Flow

1. Pre-treat both nostrils with topical decongestant and anesthetic 2. Attach tubing to wall oxygen or compressed air 3. Gently insert adaptor into contra-lateral nostril 4. Slowly titrate flow upward until FB expelled Noninvasive Removal of Nasal Foreign Bodies And While We’re Talking About Little Kid Noses…. Intranasal Drug Indications Intranasal Drug Dosing TXA + Nasal Tampon for Epistaxis Control Epistaxis

Where is coming from: 1 nostril, 2 nostrils, mouth? Anterior vs. Posterior Epistaxis

Stopped or actively bleeding?

Prepare the Site:

Cotton ball: lidocaine (4%) + neosynephrine (Afrin) Epistaxis: Anterior bleeds When the bleeding has stopped….

Time to Cauterize…

Have the right equipment…...

Good Light Source Nasal Speculum Epistaxis: Anterior bleeds When the bleeding has stopped….

Time to Cauterize… Visualize Kieselbach’s Area

Hyperemic Vessels Oozing Septum Epistaxis: Anterior bleeds When the bleeding has stopped….

Time to cauterize… Liberally apply silver nitrate stick Posterior Epistaxis: Several Options

Posterior Tampon Posterior Sponge Posterior Epistaxis

Double Balloons 10Fr Foley Cath Do you need to place patients with packing on prophylactic antibiotics?

Background: Dogma says “yes”. Theory: Prevent TSS

Methods: randomized trial, 154 pts with packing

Results: Amox-Clavulanate no Abx N=78 N=76

No difference – no cases of.. sinusitis, otitis, TSS

PROSPECTIVE STUDY OF THE RISK OF NOT USING PROPHYLACTIC ANTIBIOTICS IN NASAL PACKING FOR EPISTAXIS Pepper, C., et al, J Laryngol Otol 126(3):257, March 2012 TXA + Nasal Tampon for Epistaxis Control

 There are multiple interventions that can be helpful in controlling epistaxis

 Here is a relatively new arrow to add to your quiver TXA + Nasal Tampon for Epistaxis Control

 TXA

 An anti-fibrinolytic agent  Inhibits conversion of plasminogen to plasmin  Used to decrease bleeding from trauma and surgery  Effective and relatively cheap TXA + Nasal Tampon for Epistaxis Control

Insert the nasal tampon as usual. Then saturate it with TXA (500mg in 5mL) TXA + Nasal Tampon for Epistaxis Control Nasal Septum Hematoma Nasal Septum Hematoma

 Collection of blood between the nasal cartilage and the overlying perichondrium

 Resulting ischemia

 Permanent disfigurement Nasal Septum Hematoma Nasal Septum Hematoma Nasal Septum Hematoma Nasal Septum Hematoma

Normal Appearing Septum Nasal Septum Hematoma Nasal Septum Hematoma

Equipment Nasal Septum Hematoma

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Equipment Nasal Septum Hematoma

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Equipment Nasal Septum Hematoma

 Ensure adequate topical/local anesthesia

 Small linear incision

 Suction removal of clot

 Inspect septum if possible  Document Nasal Septum Hematoma

 Nasal packing  Sterile petroleum gauze  Nasal tampon

 Oral antibiotic to cover Staph  Trimethoprim-sulfamethoxazole  Doxycycline

 Pack removal in 2-3 days Nasal Septum Hematoma Re-implantation of Avulsed Teeth Re-implantation of Avulsed Teeth

 Classification of Dental Injury  Fracture  Ellis I  Ellis II  Ellis III Re-implantation of Avulsed Teeth

 Classification of Dental Injury

 Concussion: tender but table  Subluxation loose but not displaced  Intrusion: driven into socket  Extrusion: central dislocation  Lateral luxation: ant/pos/lat mal-alignment  Avulsion: complete displacement Re-implantation of Avulsed Teeth

 If tooth is missing, attempt to find it  Especially for children  Facial X-rays  E.g. to rule out complete intrusion into maxillary sinus  Chest and Abdominal X-rays Avulsed Teeth Can Hide Avulsed Teeth Can Hide Re-implantation of Avulsed Teeth

 Primary teeth worrisome:  Aspiration  Damage to permanent teeth  Do not re-implant  Remove if nearly avulsed to prevent aspiration Re-implantation of Avulsed Teeth

 Is it a primary tooth?

 Kids start losing primary teeth at about age 5 to 6 years <4yo, primary, >7yo permanent

 Cutting edge tends to be flat

 Cutting edge of new permanent teeth will have ridges (mamelons) Re-implantation of Avulsed Teeth

Mamelons Re-implantation of Avulsed Teeth

 Permanent Teeth Implantation:  Time dependent  Can be stored in cold milk, Save-A- Tooth© or saliva (in a container, not the mouth)  Hold only by the crown  Avoid any injury to the periodontal ligament  Gentle irrigation to remove debris Re-implantation of Avulsed Teeth

Keep the Avulsed Tooth Moist Gently Remove Debris DO NOT Injury Adherent Tissue Re-implantation of Avulsed Teeth

Consider Pros and Cons of Dental Block

Infra-orbital Block for Upper Tooth Re-implantation of Avulsed Teeth

Consider Pros and Cons of Dental Block

Mental Block for Lower Tooth Re-implantation of Avulsed Teeth

Remove Any Socket Hematoma Firmly Implant the Tooth Achieve Acceptable Cosmesis

Stabilize the Tooth Re-implantation of Avulsed Teeth Re-implantation of Avulsed Teeth Re-implantation of Avulsed Teeth with Dermabond

 After re-implantation  Apply tissue adhesive (Dermabond) to both sides (mesial and distal)  Take pliable nasal bridge from respirator mask  Shape it, apply adhesive  Apply it to tooth Re-implantation of Avulsed Teeth Peri-tonsillar Abscess Aspiration Peri-tonsillar Abscess Aspiration

 Pus collection between the capsule of the palatine tonsil and the pharyngeal muscles  Presentation  Severe pain  Fever  “Hot Potato Voice”  Trismus  Polymicrobial  Group A Strep most common Peri-tonsillar Abscess Aspiration

 When in doubt, CT scan  Confirms diagnosis  Rules out more concerning conditions such as retropharyngeal abscess

Notice how the abscess pushes away from the carotid artery because of soft tissue swelling…a good thing Peri-tonsillar Abscess Aspiration

Intra-cavitary US can be very helpful Peri-tonsillar Abscess Aspiration

 Craft a sheath guard that only allows 1.5cm of needle penentration  Or a depth measured by ultrasound Peri-tonsillar Abscess Aspiration

 A curved laryngoscope or video intubation device provides…

 Tongue displacement

 Light source Peri-tonsillar Abscess Aspiration

 A cooperative patient can hold the scope and manage the gag reflex

 A cooperative patient can also hold the suction device

 This will free-up your hands and occupy the patient’s hands Peri-tonsillar Abscess Aspiration

Anesthetize locally with topical and local lidocaine Have suction available Peri-tonsillar Abscess Aspiration

 Needle aspiration is both diagnostic and therapeutic  Success rates are typically well over 90%  Re -aspiration rarely required  Discharge on appropriate oral antibiotic  E.g. clindamycin or amox/clavulanate Peri-tonsillar Abscess Aspiration Temporomandibluar Joint Dislocation Reduction Temporomandibluar Joint Dislocation Reduction

 TMJ Dislocation

 Nontraumatic  Caused by extreme opening of the mouth  Yawning, dystonia, vomiting, dental procedures  No imaging required

 Traumatic  Imaging required prior to manipulation Temporomandibluar Joint Dislocation Reduction

 Traditional techniques subject the performer to potential injury Temporomandibluar Joint Dislocation Reduction

 The Wrist Pivot Technique is effective and subjects the performer to less potential injury  Face the patient  Place thumbs at the apex of the mandible  Exert cephalad force with the thumbs  Exert caudad force with the fingers  Pivot the wrist Temporomandibluar Joint Dislocation Reduction

The Wrist Pivot Technique Temporomandibluar Joint Dislocation Reduction Posterior Sterno-Clavicular Dislocation Unknown Posterior Sterno-Clavicular Dislocation Unknown Posterior Sterno-Clavicular Dislocation Posterior Sterno-Clavicular Dislocation

 A rare but potentially life-threatening injury  20X less common than anterior sternoclavicular dislocation

 Requires significant force  Posterior blow to the shoulder, driving the clavicular head backward  Direct anterior blow to the clavicular head Posterior Sterno-Clavicular Dislocation

 Complications include:  Pneumothorax  Superior vena cava laceration/obstruction  Subclavian artery or vein laceration/obstruction  Tracheal obstruction/laceration  Brachial plexus palsy  Acute thoracic outlet syndrome Posterior Sterno-Clavicular Dislocation

 Diagnosis  Chest X-ray  CT Scan (most accurate)  High clinical suspicion

 Immediately access and address the ABC’s Posterior Sterno-Clavicular Dislocation

 Chest X-ray  Look for asymmetry of the clavicular heads on the AP view Posterior Sterno-Clavicular Dislocation Posterior Sterno-Clavicular Dislocation Posterior Sterno-Clavicular Dislocation Posterior Sterno-Clavicular Dislocation

 CT Scan will give you the answer if time allows Posterior Sterno-Clavicular Dislocation

 Closed Reduction Technique Posterior Sterno-Clavicular Dislocation

Think About It in the Right Situation Reduce It if It will Save Your Patient’s Life Tension Pneumothorax Primary Spontaneous Pneumothorax (PSP)

 Occurs without precipitating event: e.g. trauma

 No known lung disease

 Often younger patients

 Risk Factors:  Smoking  Catamenial (thoracic endometriosis)  Marfan Syndrome PSP

 Up to a 50% recurrence rate

 Most within the 1st year

 Risk factors of recurrence:  Male gender  Tall stature  Low body weight  Continued smoking Secondary Spontaneous Pneumothorax (SSP)

 Associated with known lung disease

 COPD  Cystic fibrosis  Malignancy  Necrotizing pneumonia  Pneumocystis  TB Clinical Presentation

 Sudden onset of unilateral pleuritic chest pain with dypnea

 PE:  Hypoxia (usual)  Decreased chest excursion  Diminished breath sounds  Hyper-resonant percussion Diagnostic Tests

 Bedside Ultrasound  Immediately available and very accurate

 Chest X-Ray  Usually helpful

 CT Scan  Especially helpful in identifying large COPD-related bullae Bedside Ultrasound

Look For Evidence of Lung Sliding CXR Helpful Most of the Time CXR CXR CT Scan: Great for Picking Up “Invisible” Pneumothoraces Beware: Giant Bullae Can Mimic Pneumothorax

When in doubt, CT Scan! Categorize the Size as Small or Large: Treatment Options are Based on Size

At the Apex: <3 cm, Small 3+ cm, Large

At the Hilum: <2 cm, Small 2+ cm, Large Treatment Options

 Supplemental oxygen with observation  Can increase air re-absorption rate by 6-fold

 Catheter aspiration

 Small-bore catheter insertion (6-12 F)

 Tube thoracostomy (20-28 F) Small-bore Chest Tube

 An option for small pneumothoraces  Seldinger catheter-over-wire technique  Less tissue dissection  Less pain  No need for suturing  Shortens hospital LOS Small-bore Chest Tube Small-bore Chest Tube

•Position the patient •Mark the “Safety Triangle” •Anesthetize the skin and deeper tissues Small-bore Chest Tube

Passing the guide wire through the finder needle Small-bore Chest Tube

•Make a small incision at the insertion point to facilitate catheter passage •Direct catheter cephalad •Ensure all side holes are within the pleural space Tension Pneumothorax

Diagnose tension pneumothorax based on BOTH the physical exam and the CXR

Deep Sulcus Sign + Mediastinal Shift = TP Tension Pneumothorax Tension Pneumothorax Tension Pneumothorax True Tension Pneumothorax: A Procedural Emergency

Traditional Approach True Tension Pneumothorax: A Procedural Emergency

Traditional Approach

14g Angiocath Select a Longer Catheter 3.35 inch Lateral Approach

 US military studies prove the life-saving value of needle decompression of tension pneumothorax in the field

 They believe a lateral approach is safer True Tension Pneumothorax: A Procedural Emergency

Risk of Anterior Approach: Lung Injury Lateral Approach

 3.25 inch 14g angiocath

 Anterior axillary line

 4th intercostal space

 Insert above the rib True Tension Pneumothorax: A Procedural Emergency

Lateral Approach Less Likely to Cause Lung Injury Tension Pneumothorax

Practice at Your Local Simulation Center Modified Valsalva Maneuver for Supra-Ventricular Tachycardia

Fun and Ecstasy at the Bedside SVT We Know & Love

Narrow, Fast, Regular, Pretty Orthodromic SVT Orthodromic SVT

A-V Nodal A-V Re-entrant Re-entrant Tachycardia Tachycardia

Frankly, making this distinction may be important to an EP Cardiologist, but it really doesn’t matter to me Always Examine the Baseline ECG for Delta Waves of WPW

NOTE: The delta wave is only evident at baseline, not during the SVT event. Always Examine the Baseline ECG for Delta Waves of WPW Orthodromic SVT

Narrow, Fast, Regular, Pretty SVT SVT: Treatment Considerations

For unstable SVT, whether ortho- or antidromic, immediately prepare for synchronized cardioversion WPW-Induced Orthodromic SVT: Treatment Considerations

 For usual (orthodromic) and stable SVT:

 Vagal maneuvers (+/-)  Slow rate of impulse formation in the SA node  Slow conduction velocity in the AV node

 Carotid sinus massage  Caution in patients with stroke/TIA or carotid bruit

 Valsalva maneuver

 Diving reflex Valsalva Trick to Increase Success Rates

VS

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2 3 Valsalva Trick to Increase Success Rates

• Standard Maneuver: 17% successful

• Modified Maneuver: 43% successful

• NNT 3

Appelboam: Lancet 2015 Modified Valsalva Maneuver for Supra-Ventricular Tachycardia

Fun and Ecstasy at the Bedside Refractive VF Electric Storm Electric Storm

 Rarely, a patient’s ventricular fibrillation persists in spite of…

 At least 3 rounds of IV epinephrine

 At least 3 defibrillation attempts

 At least 300mg IV of amiodarone (or an equivalent anti-dysrhythmic) Electric Storm

 This situation, referred to as Electric Storm…

 Activates the sympathetic nervous system

 Results in a surge of endogenous catecholamines

 The theory is that this explains the failure of traditional management in patients with refractive VF Electric Storm

 Another potentially effective intervention…

 Double sequential external defibrillation:  Pads placed A-P AND A-Apex  Maximal energy settings  Simultaneous discharge

 Journal American College of Cardiology 1994  Prehospital Emergency Care 2015 Electric Storm

 Esmolol, bolus and drip, has been reported to be effective in several small studies  Bolus 0.5mg/kg  Drip up to 0.1mg/kg/hr

 Resuscitation 2014  Circulation 2000  Circulation Journal 2010 Refractive VF Electric Storm

Pad Placement Refractive VF Electric Storm

Pad Placement Refractive VF Electric Storm

Consider esmolol and double sequential defib in the VF patient who fails aggressive standard therapy Foreskin/Scrotum Zipper Entrapment Zipper Entrapment: Preparation

 What’s involved: Foreskin or Scrotum? Zipper Entrapment: Preparation

 What part of the zipper is involved: Teeth or Sliding Plate? Zipper Entrapment: Preparation

 Strongly consider procedural sedation in children  Ketamine as excellent choice

 Other analgesic options  IN fentanyl (1-1.5 mcg/kg)  Local injection of lidocaine or bupivacaine without epinephrine Zipper Entrapment: Preparation

 Avoid dorsal penile blocks in children unless in combination with procedural sedation

 Cut off adherent trousers  Less potential for trauma  Better visualization Zipper Teeth Entrapment

Cut across the teeth horizontally above or below the entrapped tissue

Gently pull teeth apart Zipper Plate Entrapment

Reasonable Options:

Cut the Median Bar

Separate the Anterior and Posterior Plates Cut the Median Bar Separate the Anterior and Posterior Plates

Rotate the flathead screwdriver 90 degrees to separate the plates Foreskin/Scrotum Zipper Entrapment Shoulder Dislocation Reduction Shoulder Dislocation Reduction

It’s shallow anatomy subjects the shoulder joint to dislocation Shoulder Dislocation Reduction

 Anatomic Classification  Anterior (95%)  Posterior (2-4%)  Inferior (Luxatio Erecta 1%)  Commonly associated injuries  Hill Sacks Injury  Cortical depression of the humeral head secondary to glenoid rim impaction  Bankart Injury  Avulsion of the glenoid labium  Greater Tuberosity Fracture Shoulder Dislocation Reduction

ANTERIOR DISLOCATION Shoulder Dislocation Reduction

POSTERIOR DISLOCATION Shoulder Dislocation Reduction

INFERIOR DISLOCATION Shoulder Dislocation Reduction

HILL SACHS Shoulder Dislocation Reduction

BANKART Shoulder Dislocation Reduction

GREATER TUBEROSITY FRACTURE Shoulder Dislocation Reduction

 Pre-procedure Preparation:

 None  Cooperative patient  Immediate reduction possible  Scapular Manipulation Technique  Cunningham Technique  External Rotation +/- Milch Technique

 Intra-articular Anesthesia

 Procedural Sedation  Ketamine works well in this situation Shoulder Dislocation Reduction

 Intra -articular Anesthesia

 Lateral or Posterior Approach  20cc 1% lidocaine Shoulder Dislocation Reduction

 Many reduction techniques have been described

 Get used to two of your favorites:  One you can perform immediately without pre- procedure sedation/analgesia  One that never fails you

 Let’s quickly review a few of the more common ones Shoulder Dislocation Immediate Reduction

Scapular Manipulation Shoulder Dislocation Immediate Reduction

Davos Shoulder Dislocation Immediate Reduction

Cunningham Shoulder Dislocation Immediate Reduction

Cunningham Shoulder Dislocation Reduction

Stimson Shoulder Dislocation Reduction

Stimson + Scapular Manipulation Shoulder Dislocation Reduction

External Rotation +/- Milch Shoulder Dislocation Reduction

External Rotation +/- Milch Shoulder Dislocation Reduction

Fares Shoulder Dislocation Reduction

Spaso Shoulder Dislocation When All Else Fails

Traction/Counter-traction Shoulder Dislocation When All Else Fails

Traction/Counter-traction Shoulder Dislocation Reduction

Technique for an Inferior Dislocation Shoulder Dislocation Reduction

Technique for a Posterior Dislocation Shoulder Dislocation Reduction Nursemaid’s Elbow Nursemaid’s Elbow

 Axial traction mechanism  Subluxation of the radial head within the annular ligament  Sudden onset of elbow pain and splinting  Typical age 1-4 years old Nursemaid’s Elbow

 The diagnosis can be made with the history and physical exam in most instances

 X- rays are not required in straight-forward cases  Obtain them if your pretest probability for fracture is intermediate or high  Obtain them if your reduction efforts are unsuccessful or complicated Nursemaid’s Elbow

 Reduction techniques most commonly described:  Supination/Flexion  Pronation/+/- Extension  There is not enough evidence to choose one technique clearly over the other  My practice:  Since I feel I have one chance for the Golden Ring, I perform both during the same procedure Supination/Flexion

Keep your thumb over the Radial Head Feeling a “Click” = Success Pronation/+/- Extension

Keep your thumb over the Radial Head Feeling a “Click” = Success Nursemaid’s Elbow Hematoma Block Hematoma Block

 HB’s are a safe and efficacious method to reduce long bone fractures  Alternative to procedural sedation  Relatively quick  Easily mastered  Cheap  Contraindications:  High risk of procedural bleeding (e.g. excessive anticoagulation)  Open fractures  Contaminated injuries  Very young children Hematoma Block

Step 1: Vigorously clean the injection site Hematoma Block

Step 2: Step along with the needle until it “falls” into the fracture with loss of resistance Hematoma Block

Needle

Fracture

Step 2: You can also use ultrasound guidance to ensure that the hematoma is entered. Hematoma Block

Step 3: Confirm appropriate location by aspirating dark hematoma blood. Inject 10cc 1% lidocaine Hematoma Block

Step 4: Wait 10-15m minutes. Then reduce and splint the fracture. Obtain post-reduction imaging. Hematoma Block Repairing Thin and Fragile Skin Lacerations Repairing Thin and Fragile Skin Lacerations

 Elderly patients frequently suffer superficial avulsion lacerations through thin and fragile skin

 Surgical repair is challenging

 If tissue adhesive isn’t the answer, Steri-Strips® + sutures may do the trick Repairing Thin and Fragile Skin Lacerations Repairing Thin and Fragile Skin Lacerations Repairing Thin and Fragile Skin Lacerations Repairing Thin and Fragile Skin Lacerations Transthecal Digital Block Transthecal Digital Block

 Traditional digital blocks, performed correctly, are very effective in providing total anesthesia to fingers  But require multiple injection sites Transthecal Digital Block

Transthecal

Traditional Transthecal Digital Block

 The transthecal block, if performed correctly, requires only a single injection site

Apply Pressure Here Transthecal Digital Block

 Injection point = MCP and midline of the involved finger  Apply pressure proximally to ensure distal migration of the anesthetic

Apply Pressure Here Apply Pressure Here “One Injection” Digital Block

 Injection point = intersection of distal palmar crease and midline of the involved finger  Apply pressure proximally to ensure distal migration of the anesthetic

Apply Pressure Here Transthecal Digital Block Subungual Hematoma Subungual Hematoma

 A common and very painful injury

 Treatment is straight forward and very effective

 Thermal cautery is the preferred technique

 Pearl: If cautery is immediately painful prior to trephination, STOP!  The hematoma is not large enough to evacuate Subungual Hematoma

Shield with Gauze Blood is Under Pressure Subungual Hematoma

Avoid These Techniques if Possible Consider a Digital Block if You Use Them Subungual Hematoma Avulsed Nail Avulsed Nail

 A common and painful injury

 Search for and repair any significant nail bed laceration

 Some advocate NOT re-implanting the avulsed nail

 But if you are an “implanter”…. Avulsed Nail

 A common and painful injury

 Search for and repair any significant nail bed laceration

 Some advocate NOT re-implanting the avulsed nerve

 But if you are an “implanter”…. Avulsed Nail

Tissue Adhesive

Transverse Figure-of-Eight Technique Avulsed Nail

Transverse Figure-of-Eight Technique Avulsed Nail

Transverse Figure-of-Eight Technique: Nail Substitute Avulsed Nail

Tissue Adhesive Technique Avulsed Nail

Tissue Adhesive Technique Avulsed Nail Loop Technique for Abscess Drainage Loop Technique for Abscess Drainage

 Cutaneous abscesses are a common condition requiring treatment

 Consider them to equal MRSA

 I&D alone is often all that is needed  Antibiotics only for significant cellulitis or immunocompromised patients

 Abscess packing is rarely required  Painful, not helpful Loop Technique for Abscess Drainage

 Simple linear incision is the traditional approach

 However, the Loop Technique offers an alternative for…  Abscesses located in cosmetically sensitive areas  Abscesses requiring longer incisions  Children/parents who are scalpel phobic  An alternative to packing Loop Technique for Abscess Drainage

Step 1: •Local anesthesia or procedural Step 1: sedation •Local anesthesia or procedural sedation •Small stab incision•Small with stab11-blade incision with 11-blade •Break-up loculations with•Break-up curved loculations hemostat with curved hemostat Loop Technique for Abscess Drainage

Step 2: •Tent the skin on the opposite side with hemostat •Make second stab incision •Irrigate abscess thoroughly Loop Technique for Abscess Drainage

Step 3 •Protrude the end of the hemostat through the second incision •Grasp the vessel loop or packing tape Loop Technique for Abscess Drainage

Step 4 •Pull the vessel loop or tape through the initial incision Loop Technique for Abscess Drainage

Step 5 •Loosely tie the vessel loop or tape Loop Technique for Abscess Drainage

Step 6 •Schedule vessel loop or tape removal for 5-7 days Loop Technique for Abscess Drainage Pediatric Gastrostomy Button Replacement Pediatric Gastrostomy Button Replacement

 Gastrostomy buttons are increasing in prevalence

 Initial devise placement requires anesthesia and endoscopy

 Subsequent adjustments and replacement can often be done safely at the bedside Pediatric Gastrostomy Button Replacement Pediatric Gastrostomy Button Replacement

 Immediately replacing an accidentally dislodged button has several benefits:

 Obviates need for a more invasive procedure

 Allows continued nutrition and hydration

 Allows continued medication administration Pediatric Gastrostomy Button Replacement

 There is a major risk to avoid:

 Disruption of the track

 Misplacement of the device into the peritoneal cavity

 Peritonitis Pediatric Gastrostomy Button Replacement

 Absolute contraindications to replacement

 An immature track (<3-4 weeks since placement)

 Purulent, bloody, bright green or fecal drainage

 Relative contraindication:

 Jejunal termination of the device Pediatric Gastrostomy Button Replacement Procedure

 Step 1:  Confirm that the track is mature  Step 2:  Access the stoma for any contraindication

 Step 3:  Consider analgesics/anxiolytics Pediatric Gastrostomy Button Replacement Procedure

 Step 4:  Confirm that the balloon is intact by injecting and then withdrawing 5mL of water Pediatric Gastrostomy Button Replacement Procedure

 Step 5:  Lubricate the tube and insert without significant force Pediatric Gastrostomy Button Replacement Procedure

 Step 6:  Inflate the balloon with water, NOT saline Pediatric Gastrostomy Button Replacement Procedure

 Step 7:  Confirm placement with contrast (ideally) or with easily recovered sterile saline Pediatric Gastrostomy Button Replacement Procedure

 Step 7:  Confirm placement with contrast (ideally) or with easily recovered sterile saline Pediatric Gastrostomy Button Replacement

 Trouble shooting  If a button of the same size won’t pass, try a smaller size

 Try cautious stretching of the track  By passing progressively larger tubes or partially filling balloon and pulling back

 Pass a Foley catheter to prevent track closure  Clamp the tube to prevent gastric discharge Pediatric Gastrostomy Button Replacement Trochanteric Bursitis Trochanteric Bursitis

 A common cause of non-traumatic lateral hip pain

 Can be severe and disabling

 Too often over-tested with Xrays, CT, MRI

 Diagnosis can be made at the bedside with a focused physical exam Trochanteric Bursitis Anatomy

Given its large size and no worrisome local structures (e.g. large vessels/nerves, bowel, lung), this is a great bursa for the novice to treat Trochanteric Bursitis

 Identify maximal tender point (MTP)  Sterilize the area  Enter perpendicular to skin at MTP  At bone, withdraw 2-3 mm, aspirate and inject X  Inject in fan-like Photo distribution  22-gauge, 1.5” needle Censored  60-80mg of DepoMedrol®  5-10cc bupivacaine Trochanteric Bursitis Injection

Direct needle to MTP, inject above periosteum Pes Anserine Injection Once you’ve mastered the trochanteric bursa technique, how about the anterior subacromial bursa?

Direct needle to underside of acromial shelf & inject Lateral Subacromial Bursa Injection

Direct needle under acromial shelf using index finger as target. Gleno-Humeral Injection

Direct under acromial shelf & inject. Acromioclavicular Joint

Acromioclavicular Joint

Identify groove and mark Direct needle straight down into joint, ~1 cm depth 0.5cc–1cc steroid 1-2 cc bupivacaine 25-gauge 1” needle Lateral Epicondyle Injection

Inject around origin of extensor carpi radialis brevis Medial Epicondyle Injection

Inject around medial epicondyle DeQuervains Tenosynovitis

Finkelstein’s Test: Grasping thumb with ulnar deviation at the wrist causes pain over APL & EPB tendons DeQuervains Tenosynovitis

MTP is usually the abductor pollicis longus at the radial styloid (snuffbox) Wrist should have slight ulnar bend May direct toward or away from fingers 25 -gauge 1-1.5” needle  0.5-1cc steroid  0.5-1cc bupivacaine Trochanteric Bursitis Captain Morgan Technique for Dislocated Hip Reduction Hip Dislocation

 90% are posterior

 Complications are common  50% other fractures or significant injuries  10 -20% incidence of avascular necrosis Time dependent  10 -15% incidence of sciatic nerve injury Time dependent Posterior Hip Dislocation Captain Morgan Technique for Dislocated Hip Reduction

 Traditional posterior hip reduction techniques are effective, but require brute strength Captain Morgan Technique for Dislocated Hip Reduction

 Captain Morgan Technique  Consider procedural sedation if time and patient status allow  Flex patient’s hip to 90°  Use your knee as fulcrum in the patient’s popliteal fossa  Exert upward force with your knee  Exert downward force on lower leg with your hand  Perform gentle adduction/internal rotation +/- abduction/external rotation  Be patient Captain Morgan Technique for Dislocated Hip Reduction Captain Morgan Technique for Dislocated Hip Reduction Patella Dislocation Reduction Patella Dislocation Reduction

 Most common  In 20’s and 30’s age group  Women  Lateral dislocation

 It can be diagnosed at the bedside

 Reduction technique is simple and effective

 Post-reduction X-rays indicated Patella Dislocation Reduction

Pre-reduction X-rays are not always required, but if they are ordered… Patella Dislocation Reduction

Reduction Technique Patella Dislocation Reduction Knee Dislocation Reduction Knee Dislocation Reduction

 An orthopedic and vascular emergency

 Four major ligaments injured  Anterior Cruciate  Posterior Cruciate  Medial Collateral  Lateral Collateral

 High likelihood of a popliteal artery injury  Firmly anchored above and below the popliteal fossa Knee Dislocation Reduction

 Beware of the spontaneously reduced knee  Distal ischemia may still be present

 Examine for gross instability  E.g. hyperextension of the knee

 Examine for distal vascular compromise  E.g. doppler pedal pulses, ABI Knee Dislocation Reduction

 Dislocations can be in any position  Anterior  Posterior  Lateral  Rotatory  NOTE: posterolaterl dislocations are irreducible by closed reduction Knee Dislocation Reduction

 Procedure  Procedural sedation if hemodynamics will allow  Stabilize the femur  Distal traction on the lower leg  Reverse the direction of the dislocation  E.g. for an anterior dislocation, apply posterior force to the proximal tibia and anterior force to the distal femur  Document distal vascular status before and after the reduction Knee Dislocation Reduction Knee Dislocation Reduction Ankle/Brachial Index for Lower Extremity Trauma Ankle/Brachial Index for Lower Extremity Trauma

 Hard signs of a lower extremity vascular injury

 Active hemorrhage  Expanding/pulsatile hematoma  Bruit/thrill over the wound  Absent distal pulses  Extremity ischemia Ankle/Brachial Index for Lower Extremity Trauma

 ABI Procedure  Use appropriately sized BP cuff  Inflate cuff until Doppler signal disappears  Deflate cuff slowly and record when Doppler pulse is first audible

 Measure both brachial arteries  Measure both the dorsalis pedis and posterior tibial arteries of the involved leg Ankle/Brachial Index for Lower Extremity Trauma

 ABI= higher of the ankle SBP/higher of the arm SBP

 Normal >/= 0.9 to 1.3

 <0.9 = likely vascular injury

 >1.3 = likely calcified vessel Ankle/Brachial Index for Lower Extremity Trauma Ankle Dislocation Reduction Ankle Dislocation Reduction

 Usually associated with fractures

 Posterior dislocation most common

 A high energy injury  Check for other injuries Ankle Dislocation Reduction

 Procedure for posterior dislocation  Provide procedural sedation if patient condition allows  Supine position  Monitor airway  Knee slightly flexed  Relaxes the Achilles tendon  Achieved by hanging foot over the end of the gurney  Assistant maintains knee in flexion during the procedure Ankle Dislocation Reduction

 Procedure for posterior dislocation  Hold foot in plantar flexion  Recreating the position of injury  Axial traction  Anterior pressure on heel  Posterior pressure on distal tibia  Check and record neuro-vascular exam pre- and post-procedure  Obtain post-reduction X-rays Ankle Dislocation Reduction Ankle Dislocation Reduction Sacroiliac Joint Subluxation Reduction Sacroiliac Joint Subluxation Reduction

 A very common cause of acute low back pain  Atraumatic  Minor mechanism: e.g. bending or twisting  Acute and severe pain localized to the lateral lower back  Under recognized, over X-rayed and almost never treated with point-of-care manipulation Sacroiliac Joint Subluxation Reduction

 Exam will reveal a tender SI joint which demonstrates decreased motion with flexion  Distal neuro-vascular exam is normal Sacroiliac Joint Subluxation Reduction

This Requires a Live Demonstration Thanks for Your Kind Attention!