Trying to suture or staple a scalp laceration is oftentimes a hairy proposition for emergency physicians who repair these types of wounds regularly. Although the “hair apposition technique” method is one option, if one opts for sutures or staples, the most difficult part of the procedure is trying to avoid trapping hair strands within the wound, which may cause wound dehiscense, a foreign body reaction, or a local infection. 

Trick of the Trade: Part the hair away from the scalp laceration with petroleum-based jelly

A useful solution to this problem is through the use of a thick petroleum-based ointment to displace the hair to each side of the wound. Bacitracin or similar topical antibiotic derivatives can be used, as can petroleum jelly.

A healthy 4 year-old boy is brought in by mom for a plastic bead up his nose. The mom states, “The last time the other doctors had to be called, and it took forever. Oh, and I have to pick up his brother from school in 30 minutes. Can you get it out, doc?” The patient is squirming even as you take a quick peek at his nose, but you catch a glimmer of the bead up his right nare.  

Trick of the trade: Remove nasal foreign body with Foley catheter (or Katz extractor)

Foley Catheter (8 French)

1. Don protective gear and plan for adequate lighting
2. Obtain and test balloon functionality of a 6F (or 8F) Foley catheter
3. Consider wrapping the child in a sheet to ensure optimal procedural conditions
4. Insert the Foley tip just past the bead
5. Inflate the balloon with air
6. Pull the Foley out of the nose with gentle traction until the bead pops out!

Alternatively, the video above by Dr. Mellick demonstrates how a Katz Extractor can be used (start at 00:34 if you want to skip the introduction). This commercial device is based on the same idea, but it is more rigid, allowing for a single-handed technique. The catheter-based approach is often a favorite of emergency physicians over positive or negative pressure, glue, or forceps, because anecdotally it is better tolerated by patients and parents. However, the limited available literature is not able to support one technique over another.

Pitfalls:

1. Visualization: This technique still requires visualization. Do not insert the catheter blindly as the foreign body may dislodge posteriorly. If it does, immediately check the oropharynx.
2. Although not reported, this may be a technique theoretically to avoid in very posterior foreign bodies as they may be at increased risk for aspiration. 

Pearls

1. Have good lighting: Use a headlamp as opposed to an otoscope for visualization, as it frees up both hands to place and inflate the catheter (prior Trick of the Trade).
2. Positioning: Just like any procedure, positioning is key, and even more so in awake young children who will only give you one chance to attempt the procedure. Use a sheet or papoose board to keep the patient properly positioned. If you have a child life specialist, use him or her.
3. Nasal vasoconstriction: Consider using oxymetazoline or 0.5% phenylephrine (Neo-Synephrine). This allows for easier passage of the catheter behind the foreign body. Also consider topical lidocaine for analgesia. Often lubricant is not necessary as there is much natural lubrication from accumulated nasal discharge.

References

1. Davies PH, Benger JR. Foreign bodies in the nose and ear: a review of techniques for removal in the emergency department. J Accid Emerg Med 2000;17:91-94. PDF
2. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007 Oct; 76(8):1185-89. .
3. Fox JR. Fogarty catheter removal of nasal foreign bodies. Ann Emerg Med. 1980;9:37-8. 
4. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008 Nov;24(11): 785-92.
5. Leach AJ. Evidence based problem solving in general practice: the foreign body in the nose. JR Army Med Corps. 2000 Feb;146(1):31-2. 
6. Katz Extractor website

Disclosures: I do not have any financial ties with Katz Extractor or Foley Catheters.

You are spending a month in rural Kenya, doing an ultrasound teaching course. Your enthusiastic participants have been ultrasounding every chance they get. Unfortunately, this has caused your ultrasound gel supplies to dwindle. It will be a month before a new shipment of gel arrives from Nairobi. This gel will cost about $5 per bottle, which is a considerable expense for the local hospital’s budget.

Trick of the Trade: Homemade ultrasound gel

With a few simple and ubiquitous ingredients, you can make your own ultrasound gel to use. 

Equipment Needed 

• Corn starch
• Water
• Pot or pan
• Heat source
• Empty and clean bottle 

Technique

1. Combine 1 part corn starch to 10 parts water in a pan. Here, we use ¼ cup corn starch to 2 ½ cups water to make about 2 gel bottles full.
2. Heat this mixture while stirring constantly at medium heat for 5-10 minutes.
3. When the substance begins to boil, turn off the heat and allow the mixture to cool.
4. Pour the mixture into a clean, preferably sterilized, container. Here, we use an old commercial ultrasound gel bottle which we placed in boiling water for 10 minutes first.
5. Ultrasound away! Note that the gel should be used within 48-72 hours for best results. After that, it may begin to separate a bit.

Word of Caution

This homemade gel does not have the same bacteriostatic ingredients that are in commercial ultrasound gel. Therefore we do no recommend its use for skin and soft tissue infections.

Expert Peer Review

April 11, 2014

Top image

Patients with fingertip injuries involving the nail bed typically present to the emergency department and require meticulous repair of the nail bed to prevent long-term cosmetic and functional disability. There are several methods to repair nail beds, typically involving absorbable suture, but maybe there is a faster way with similar cosmetic and functional outcomes. 

Case

A 28 year old, left handed female comes to your ED with a chief complaint of having her left thumb slammed in a car door.  She has no past medical problems or surgeries and no allergies to medications. Her injury is shown below:

The patients finger was anesthetized with a 3 point ring block at the base of the thumb, and the nail was then removed.  There was also a small nail bed laceration that did require some absorbable sutures. After repair of the nail bed laceration, an 18 gauge needle was used to place 4 holes in the nail itself so that the The nail could be reinserted and secured with 4-0 vicryl sutures. But could there have been an alternative approach?

Trick of the Trade: Nail bed repair with tissue adhesive glue

Instead of sutures, tissue adhesive can be used for two purposes:

1. Repairing a nail bed laceration
2. Holding the nail in place

The picture below shows an example of how the nail can be slid back into place and secured with glue.

Evidence behind the trick:

Dermabond for nail bed laceration repair [1]

What they did

• Prospective comparison of 2-octylcyanoacrylate (Dermabond; Ethicon Inc, Somerville, NJ) vs standard suture repair using 6-0 chromic
• 40 consecutive patients

Outcomes

• Time to repair
• Cosmetic and functional outcomes at 1, 3, and 6 months

Results

• Time to repair: 9.5 min (Dermabond) vs 27.8 min (standard suture repair)
• Infection rate: 1 patient (Dermabond) vs 0 patients (standard suture repair)
• No statistical difference in physician judged cosmesis, patient perceived cosmesis, or patient perceived functional outcomes

Limitations:

• Repairs were performed by orthopedic residents and not emergency medicine residents
• Small sample size was a major issue: Only allowed for statistically significant difference in time of repair
• Dominant hand injury was < 50% of cases in both groups which may have biased functional scores
• There was a disproportionate number of stellate lacerations in the standard suture repair group (6) vs Dermabond group (3), which may have biased the results.

Conclusion: Dermabond is an efficient and effective alternative to sutures in nail bed injuries.

Take Home Message

Nail bed repair with Dermabond (and likely all tissue adhesive glues) may be a reasonable alternative to sutures for both nail bed laceration repair itself, as well as to hold the nail in place.

Post updated May 26, 2014 (22:47 PST)

References

1. E.J. Strauss, W.M. Weil, C. Jordan, and N. Paksima, "A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries.", The Journal of hand surgery, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18294549

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. For cricothyroidotomy, a procedure that is essentially performed blind due to blood and small spaces, adding additional realism means crafting a model that not only contains the correct anatomic landmarks, but also has the ability to bleed significantly enough to obscure the view of the performer. To borrow a phrase from Cliff Reid and from the military, to be able to perform these procedures expertly we must “train like we fight” [1,2]. The following trick involves making a silicone-based skin layer which will bleed profusely when cut into.

Simulation Trick of the Trade: A Bleeding Cricothyroidotomy Model

Procedure

1. Get a 8”x 8”cake pan and liberally spray with silicone releasing agent

2. Use a silicone rubber mix, such as Dragon Skin which is used for movie costumes and in animatronics. Combine approximately 1/3 cup of part A with 1/3 cup of part B, along with several drops of a coloring agent in a cup. 

PART A

PART B

COLORING AGENT

3. Pour the silicone mixture into the prepared cake pan and spread to make a very thin layer (about 2 mm). Any bubbles in the mixture should rise to the top and pop by themselves. You can speed this process by agitating the mix, such as beating it against a solid object.

4. Leave the cake pan on a level surface for whatever the recommended drying time is for the product you picked. Typically this is an overnight process.

5. Remove the thin sheet of silicone from the pan. Cut a 4”x 8”section and a 3”x 3”square.

6. Cut off the Luer lock end of a 32-inch IV extension set and rest this end on top of the 4”x 8”rectangle piece, along with a small amount of polyfill material (a polyester stuffing commonly used in pillows and clothing). The polyfill helps disperse the “blood” evenly in the pocket and helps obscure view of the cricothyroid membrane when the skin is incised.

7. Glue the smaller silicone square on top of the larger rectangular piece, while sandwiching in the IV tubing. Use silicone glue to make sure all the edges are sealed to create a completely closed pocket between the two silicone pieces. Be careful to not get any glue on the tip of the IV tubing. To ensure all the edges are air tight, attach a 20-30 mL syringe on the IV tubing and gently apply suction. If you have a leak, continue to liberally apply glue to the margins of the 3”x 3”square until it is sealed.

8. Let dry again overnight.

See it in Action!

The video below shows how using this bleeding model can supplement a cricothyroidotomy simulation procedure but adding the realistic effect of active bleeding.

Quick pointers

1. For heightened realism, lay this skin over the top of a sheep or pig trachea as they have the anatomic landmarks most similar to human anatomy with a realistic tissue feel. If unavailable, a plastic training model would work. There are also some jerry rigged models you can make with ventilator tubing and tape that would work in a pinch. The end product model can be a bit messy so I would be hesitant to put this skin over something of significant financial value such as the majority of the high fidelity simulation manikins.
2. Thinness is key. Getting the layer of silicone to be thin and even is quite challenging but well worth the extra effort. If the “skin”is too thick, you won’t be able to palpate landmarks thus hindering the realism of the procedural trainer.
3. Most of these supplies can be ordered online. The polyfill material used in step 6 can be purchased at any hobby shop.
4. I used a commercially available 2-part silicone mix that has a slow set up time. You may be able to speed the process along by using a mix that has a faster set up time. For me, it takes at least 2 days (of mostly drying time) to fully make the “bleeding skin” model.

Edited by: Nikita Joshi MD Associate Editor

References

1. Biddinger PD, Baggish A, Harrington L, et al. Be Prepared —The Boston Marathon and Mass-Casualty Events. N Engl J Med. 2013. May 23; 368(21): 1958–60. PMID: 23635020.
2. Reid C. How You Train is How You Fight. Resus.Me. Jan 1, 2014. Accessed May 20, 2014.

This post contains images and references to several commercial products.  I have no financial stake in the companies that make these products and no conflicts of interest to disclose.

You see a patient with a large V-shaped laceration under tension requiring suture repair. Resist the temptation to simply pull the edges together and close the laceration with simple interrupted or running sutures. Excessive tension on a flap edge during the healing process can compromise its blood supply. This causes ischemia to the healing tissue, which in turn makes that flap edge more likely to dehisce, necrose, and become infected.

Trick of the Trade:

Laceration repair using V-to-Y flap technique

Consider reducing the wound tension by converting the V-flap in to a Y-shaped flap using a carefully placed half-buried horizontal mattress suture (also known as a corner suture).  An extra few minutes spent planning this closure will facilitate easier immediate closure and create a better long term outcome for your patient.

Video from Dr. Brian Lin’s website (LacerationRepair.com)

 For a more detailed diagrammatic explanation of this technique, visit the full blog post at my site.

Want to hear more from Dr. Brian Lin?

Brian will be one of the featured speakers at the 2015 High Risk Emergency Medicine Conference in Hawaii. There he will be talking about not only Advanced Laceration Management but also Abdominal Vascular Emergencies, Burns, and Eye Emergencies!

Insect removal from the ear is a foreign body removal procedure with unique considerations. First, insects are friable. Have you ever squashed a house centipede? It’s like their 700 legs are spring-loaded to fall off instantly when touched. This characteristic makes mechanical removal by alligator forceps or cerumen loops less reliable. Second, they are alive which means they can move during your attempted extraction procedure.

Trick of the Trade

Use a Frazier suction device to remove the intra-aural critter.

Prep for success: First achieve inner peace

The idea of having a critter in one’s ear can be very disconcerting. Consider sedation for the patient to optimize patient comfort and tolerance of the procedure. Although I am becoming a big fan of ketamine, I can only imagine that if any patient is going to have an emergence reaction, it’s the one who believes s/he is actively living out a horror movie… nonetheless it is recommended in Roberts and Hedges [1].

Prep for success: Prevent addition damage

Before extracting the insect, you must kill it or otherwise immobilize it to prevent ongoing intra-aural damage by the insect. Many providers drown the insect in viscous lidocaine. We used 1% NON-viscous lidocaine. Although a small 1993 study showed that microscope immersion oil killed cockroaches faster than lidocaine (27 vs 41 seconds), finding immersion oil in the today’s Emergency Department may be challenging [2]. There still remains much debate about which solution is the best to immobilize/kill the insect.

Frazier Suction Technique

The Frazier suction device, often found in your ENT kit, should be connected to low continuous suction. Once you are convinced that the insect is dead, slowly advance the suction catheter into the patient’s external ear canal. Be sure to inform the patient of each step to avoid accidental head movement. Occlude the insufflation port to suction out the contents of the patient’s ear canal. Once no more liquid returns, withdraw the catheter and hopefully you will be the proud owner of a dead insect.

Our team felt that this suction-based technique is superior to a manual extraction of the insect with forceps, because it would seem to cause less “shredding” of the insect into smaller debris pieces. Creating such debris should be avoided, according to Tintinalli [3].

References

1. Roberts JR, Catherine BC, Todd WT, Jerris RH. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th edition. 2014. (pages 1316-7).
2. Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study. Ann Emerg Med. 1993 Dec;22(12):1795-8. PMID: 8239097.
3. Tintinalli, JE, J. Stephan S. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th edition. New York: McGraw-Hill, 2011 (page 1556).

For plastic bead removal from the ear, read another approach to intra-aural foreign body removal.

Your patient presents with an ocular burn after accidentally splashing an industrial acid on his face. You, however, can not seem to find the ever elusive eye pH paper to track her initial and serial pH’s during copious ocular irrigation. Now what?

Trick of the Trade:
Use a urine dipstick reagent strip to check eye pH

1. Cut the dipstick strip so that pH is the last box.
2. Gently touch the strip to the patient’s eye.

Caution

• Be careful of the sharp edges on the trimmed dipstick strip when touching the patient’s eye.
• Note that a urine dipstick can only detect a pH range of 5-8.5. Anything outside these ranges will require the eye pH paper, which can detect a range of 1-14.

References

Although no literature could be found on this in PubMed, it seems to be a fairly accepted practice:

1. University of Ottawa Primary Care Ophthalmology website on eye irrigation
2. Royal Children’s Hospital of Melbourne website on pediatric eye injuries

Credit for the trick goes to Dr. Eugene Izsak (Director Pediatric Emergency Medicine, Promedica Toledo Children’s Hospital; Clinical Professor of Pediatrics and Emergency Medicine, University of Toledo College of Medicine)

Application of fluorescein is a vital part of the workup of ocular complaints. Despite some studies showing questionable support, the typical cited clinical concern for stored fluorescein solutions is contimination with Pseudomonas and risk for iatrogenic infection with associated ulcer formation [1][2][3][4]. Subsequently, single dose sterile strips have become the standard agent stocked in most EDs. Many patients, especially children, can be apprehensive of the application of the physical strip directly to the eye, and are more comfortable with the concept of eye drops. In this post, we review multiple technique to create fluorescein solutions and additional tips for utilization that may be integrated into your practice, depending on the supplies available to you.

STRIP-IN-SYRINGE

This technique was first described in a guest post from Dr Ian Brown. The strip is placed directly into the syringe, and sterile saline is drawn in with the strip. The blunt filling needle is then removed, and the solution is ready for application.

Figure 1. Strip-In-Syringe Technique

MIX-IN-PACKAGING

This technique, utilizing a respiratory saline ampule and the strip packaging, is nicely photographed and explained in our prior post by Dr. Sam Ko and Dr. Kimberly Chan.

DAB-AND-WITHDRAW

Another technique contributed by ALiEM-AAEM Fellow Dr Matt Zuckerman creates a solution directly in the syringe or respiratory ampule of saline. If using a 10 cc flush, you will want to discard saline until 3 cc is remaining. Saline is expressed to create a droplet at the tip of the syringe/ampule, and the strip is dabbed directly to this droplet.  Aspirating brings the fluorescein solution back into the container. This will need to be repeated a few times to achieve appropriate concentration of fluorescein. Because the need for precise syringe-work, there is a potentially for small spills utilizing this technique, so plan accordingly.

Figure 2. Dab Technique. This can be performed with syringe or ampule of saline.

SPECIMEN CUP

This is a technique I frequently utilize in my department because of the supplies that are most readily available and some messy mishaps with the above dab-and-withdraw technique. Simply dispense 3 cc of sterile solution in a sterile specimen cup, mix the fluorescein directly into the solution, and then load into syringe. We did utilize a blunt filling needle in our example, but you may load directly into the syringe if you prefer. Left over solution in the cup can be used to explain the nature of the stain and also help motivate younger patients (“This will give you super glowing eyes!”).

Figure 3. Specimin Cup Technique

ANGIOCATH DROPPER

Regardless of the technique used to create a syringe of solution, there can be some awkwardness with application. Unlike the saline ampule, the syringe has properties which make it behave unlike a typical eye dropper. Overcoming the static friction of the syringe plunger can cause a sudden stream of fluorescein solution that can be uncomfortable or surprising for patients. This can also potentially stain clothing and lessen patients overall trust and comfort in the exam setting. I have found that applying a 24G angiocath tip to the Luer-Lok syringe can help create more control applying the solution. The small droplet size has also helped me successfully stain children who were squinting, foregoing the need to pry eyelids open and cause additional discomfort and anxiety.

Figure 4. Angiocather tip assists delivery of fluorescein solution

Happy Staining!

References

Top image credit

Distal radius fractures are among the most commonly encountered fractures in the emergency department (ED). They have been reported to account for around 25% of pediatric fractures and up to 18% of fractures in the elderly [1]. Reducing minimally displaced distal radius fractures is a procedure that can be greatly facilitated by the presence of finger traps, which help hold traction while you reduce the fracture [2]. Often While working in small 5-bed, free-standing emergency department (ED), I found myself needing to perform this vital procedure and finger traps were unavailable.

Trick of the Trade: Gauze roll finger traps

While I searched the Internet for an answer, a nurse brought me a gauze roll and asked me if it might be helpful. After some trial and error, we found a method of tying the gauze roll around the fingers in such a way that we could easily use it as a substitute for the traditional finger traps. After the procedure we made a video showing how to do it:

Technique and Lessons Learned

1. Tie one end of the gauze roll with a simple knot on the thumb, then wrap the free end around the index finger 2 times at the base of the finger
2. Slip the free end into the proximal loop and out the distal loop towards the finger tips.
3. Tighten until firm.
4. Repeat the process for the middle and ring fingers. After the 4 fingers are prepared, take the end and wrap it around the index and middle fingers proximal to the previous knots (closer to the base of the fingers) 2 times.
5. From the palmar side, take the free end and go underneath the gauze you just wrapped around the index and middle finger, and out through the dorsal side, always keeping the free end proximal to the previous loops.
6. After that, make sure it’s tightened, and attach the free end to an IV pole.
7. You are ready to commence your reduction.

References

ALiEM Copyedit

Copyedit notes:

Fantastic and quick-thinking trick on using the gauze roll as a finger trap. Suspending the arm by the hand/fingers indeed helps with distracting often impacted distal radius fractures, allowing for easier closed reduction. Notes:

1. For the sake of keeping the formatting consistent with other Tricks posts, I split your writeup into 2 paragraphs. The first sets up the problem and the second presents the solution.

2. Since not everyone watches videos, could you provide a brief summary of the premise in text form below the video? I assume you don’t overly wrap each finger to avoid finger ischemia? I’d mention that you don’t wrap the little finger since focusing on the index, middle, and ring finger are enough. Not necessary, but If you have any lessons learned from previously tested techniques, that might be helpful too.

3. Thanks for speeding up the middle of the video which shows the redundant steps for the middle and ring fingers. I always like minimizing videos to their core message and eliminating as much extraneous material as possible to be respectful of the viewer’s time. The final forceful tug at the end really shows how much weight the gauze roll can hold without the fingers slipping.

Michelle Lin, MD
ALiEM Editor in Chief; Associate Professor of Emergency Medicine, UC San Francisco

Hi Michelle,

I couldn’t figure out how to log in to make edits to the piece directly, so I figured I’d just put it here:

“Tie one end of the gauze roll with a simple knot on the thumb, then wrap the free end around the index finger 2 times at the base of the finger, after which you will slip the free end into the proximal loop and out the distal loop towards the finger tips. Tighten until firm. After that, you will repeat the process for the middle and ring fingers. After the four fingers are prepared, take the end and wrap it around the index and middle fingers proximal to the previous knots (closer to the base of the fingers) two times. From the palmar side, take the free end and go underneath the gauze you just wrapped around the index and middle finger, and out through the dorsal side, always keeping the free end proximal to the previous loops. After that, make sure it’s tightened, and attach the free end to an IV pole. After that, you’ll be ready to commence your reduction.”

What do you think?

Jacob Avila, MD RDMS
Chief Resident, Emergency Medicine, University of Tennessee at Chattanooga

A 26-year-old woman presented to an urban Detroit emergency department complaining of bilateral foot pain after walking outside in the snow for 30 minutes without shoes or socks. She was unable to ambulate secondary to the pain and swelling. Physical examination revealed bilateral pallor, doughy texture, and coolness to the touch. There was generalized tenderness to palpation throughout the digits. The overlying skin was edematous, although without signs of breakdown.

Background on Frostbite

Frostbite is a commonly encountered chief complaint during the winter months. It affects many groups of people including mountain climbers, “weekend warriors”, intoxicated individuals, those with underlying psychiatric impairment, and the homeless population. Frostbite is treated with warm water immersion in a circulating bath at water temperatures between 37 and 39 degrees C [1]. There are multiple commercial whirlpools available for reheating, however they cost thousands of dollars and are unfortunately unavailable at our institution.

Trick of the Trade: DIY Circulating Water Bath

We therefore created a whirlpool using a plastic tub, a sink with a faucet and a portable thermometer (Figure 1). The patient was placed on the standard gurney and placed adjacent to the sink. The tub was placed into the sink and filled with water until the monitored temperature was 37-39 degrees C using the hot and cold levers. Once the temperature was stable, the patient placed both of her feet into the warm water to begin re-warming. With the tub placed in the sink, there was continuous movement of water with the overflow going down into the sink drain. This effectively creates an immersion circulating water bath. This technique could be used for any body part that is easily placed into a sink and can be done with supplies readily available in most departments.

This period of re-warming takes approximately 10-30 minutes and should continue until the tissues are more pliable and distal erythema returns [2]. Our patient’s feet were rewarmed in our make-shift circulating bath. Her pain improved, the tissues became more pliable, and gradually the distal erythema returned to her toes. She was admitted to the hospital for a period of observation and pain control and was ultimately discharged following an uncomplicated course.

Take Home Points

• The treatment of frostbite includes warm water immersion at water temperatures between 37 and 39 degrees C.
• You can create a make-shift circulating bath using supplies that are readily available in most emergency departments: a plastic tub, a sink with a faucet, and a portable thermometer.
• Other important considerations for frostbite treatment include prevention of tissue refreezing [1][2][3] and adequate pain control during rewarming.

References

ALiEM Copyedit

Hey guys,

I love the the idea. Could you elaborate on the other considerations to take into account regarding the management of frostbite? Any historical or physical exam findings to consider before going for this?

Also can you describe the current products on the market and their cost?

Look forward to seeing more on this topic.

Thanks,
Sam Shaikh

Sameed Shaikh, MD
ALiEM-CORD Fellow, Emergency Medicine Resident, Wayne State School of Medicine. Founder: www.SamsStudyGuides.com

Expert Peer Review

Great idea as most Emergency Departments cannot afford an expensive whirlpool apparatus that is rarely used. Did you find that the temperature of the patient’s feet altered the temperature of the water? If so, how often did you need to check the thermometer and adjust the water temperature? Do you recall the amount of time needed for effect as during the rewarming the water is being wasted rather than reused for the same patient as would be the case with the use of a whirlpool?

Melissa Barton, MD
Former EM Residency Medical Director, Sinai Grace Hospital, Detroit, MI

Thank you for the questions. The patient began to feel improvement within 30 minutes and objective improvement began to occur around this time frame as well. The water temperature was continually monitored during her stay and the water was able to be adjusted accordingly.

Ciara Barclay-Buchanan, MD
Associate Program Director, Department of Emergency Medicine, Sinai-Grace Hospital/Detroit Medical Center/Tenet Health Systems; Clinical Assistant Professor, Wayne State University School of Medicine

Expert Peer Review

Ciara,

Very nice post with a very pragmatic approach to treating mild-moderate frostbite. One question I had upon seeing the excellent figure, was: did you have to wheel the patients stretcher over to the sink and pump it up to get the feet up to the height of the sink? I guess a more limber patient could probably sit in a regular chair and prop their feet up on the edge of the sink and accomplish this, but the stretcher pumped up method sounds a lot more comfortable.

A few comments about the management of differing severities of frostbite and the considerations when managing each (i.e. infections, necrosis, ischemia, compartment syndrome), and whether or not this modified whirlpool technique would or would not be appropriate would strengthen the post.

Lastly, you should trademark it and call it the “westside water bath”. Nice job.

Mark Favot, MD
Assistant Professor of Emergency Medicine, Wayne State University School of Medicine. Co-Director Emergency Ultrasound Fellowship, Detroit Medical Center/Wayne State University.

Thank you, Mark.

This technique is most appropriate for the acute management of mild to moderate frostbite as you stated and not likely to be an effective or appropriate therapy for more complicated cases or the sequela of frostbite.

The patient’s stretcher was in fact wheeled over to the sink and raised to its maximum height. The patient was then able to comfortably put her feet into the water. With an adjustable chair and a lower sink, I suspect you may be able to do this. Although, the chair technique would likely be easier with upper extremity frostbite injuries.

Ciara Barclay-Buchanan, MD
Associate Program Director, Department of Emergency Medicine, Sinai-Grace Hospital/Detroit Medical Center/Tenet Health Systems; Clinical Assistant Professor, Wayne State University School of Medicine

(c) Can Stock Photo

An 82-year-old female is brought into the Emergency Department by family for a several day history of progressive altered mental status. You initiate a broad workup. However, soon after initial evaluation, you are called back into the room. The patient’s vitals are as follows and concerning for septic shock and an alarming serum sodium level.

Vital signs:

• Blood pressure 89/65 (MAP 55)
• Heart rate 105 bpm
• Respiratory rate 18/min
• Temperature 38.3C

Initial labs:

• Serum sodium 105 mmol/L
• Lactate 4 mmol/L

What is the safest way to volume resuscitate a hyponatremic, hypovolemic patient?

Likely the first instinct is to provide an isotonic fluid bolus of 20-30 mL/kg for septic shock. However, in chronic, severe, symptomatic hyponatremia, sodium correction should not exceed 0.5-1 mEq/L/h with a goal of 8-12 mEq/L/d to reduce the risk of central pontine myelinolysis (also known as osmotic demyelination syndrome) [1][2]. Acutely symptomatic (<48 hours) patients can be corrected safely at a faster rate with goal of increasing sodium by approximately 1-2 mEq/L/hr for 3-4 hours.

This is a nuanced case of fluid management, but can have long-term implications for an acutely ill patient. The ideal fluid choice would allow for adequate fluid resuscitation without rapid overcorrection of the sodium concentration.

Options for fluid resuscitation

Trick of the Trade: Lactated Ringers may be the safest choice

Compared to normal saline, Lactated Ringers provides twice the volume expansion for the same degree of correction of sodium due to the lower sodium concentration per liter.

This was calculated using MDCalc, which was derived based on a great NEJM review paper [3]. For example, the amount of fluid needed to increase the serum sodium by 1 mmol/L/hr for an elderly female with an estimated weight of 60 kg and an initial sodium concentration of 105 mmol/L:

The exact amount of volume that can be given for an expected 1 mmol/L/hr increase in serum sodium will change depending on your patient’s age, sex, weight, and starting sodium value and should be calculated for each individual patient.

Bottom Line

Be concerned about rapid sodium correction in a patient with symptomatic hyponatremia. Twice the amount of volume resuscitation with Lactated Ringers can be given compared to normal saline for the same degree of sodium correction.

References

ALiEM Copyedit

1. Nice discussion of fluid resuscitation in hyponatremia. Might want to mention this is mainly a concern in chronic, severe hyponatremia and that acute hyponatremia is thought to be safely corrected at a faster rate. Also, Na of 105 is extremely rare (1 in 1,000 patients with hyponatremia in community sample: Clin J Am Soc Nephrol. 2011 May; 6(5): 960–965). Might be helpful to remind people that the same lesson (can give way more LR than NS) is also true if her Na is 120. This broadens the applicability of the case.
2. Lactate is listed as a vital sign, but it’s a laboratory value.
3. Most people will get a sodium level off a chemistry, not a VBG. Specifying VBG doesn’t seem to add anything to the case. Consider deleting. Also may remove () around units.
4. Repeatedly specify LR is “best” choice but that’s a subjective statement. Realistically it may be the “safest” choice in terms of reducing risk of demyelination.
5. Nice reference to online calculator, but MDCalc references JAMA Adrogué HJ, Madias NE. Hyponatremia. NEJM, 2000. for this. Would be more appropriate to cite the initial source and mention the MDCalc calculator as a helpful reference.
6. This concept of LR having only slightly less sodium but being able to give twice as much volume may be hard for some people to initially grasp. Would a picture help people understand this better?
7. You specify that numbers should be calculated for each patient but also seem to say that LR is a better resuscitation fluid for any hyponatremic patient at risk of rapid Na correction. Isn’t it always better to give LR to hyponatremic patients? If so, isn’t calculating for every patient unnecessary? If not, why not?

Matthew Zuckerman, MD
Assistant Professor, University of Colorado School of Medicine, Department of Emergency Medicine, Medical Toxicology Section; Creator and host of ToxNow.org

Expert Peer Review

The clinical condition of an undifferentiated hyponatremic AND hypotensive patient poses a rare but significant clinical dilemma. While Early Goal Directed Therapy (EGDT) demands rapid correction of hypovolemia when sepsis is suspected, there exists a significant risk of cerebral demyelination from overly aggressive sodium correction.

Remarkably, based on the MDCalc application (derived from Adrogué HJ, Madias NE. Hyponatremia. NEJM, 2000.), seemingly mild differences in the sodium and potassium content of Ringer’s lactate, allows for infusion of much larger crystalloid volumes compared to Normal Saline for the same degree of serum sodium increase. In this case, a “typical” 2 liter bolus of Normal Saline would be expected to increase the serum sodium concentration almost 2.5 mmol/L which is already about a quarter of the recommended daily sodium change in hyponatremia. Ringer’s Lactate (or other “balanced” crystalloid solutions such as Plasma-Lyte) would be expected to cause HALF of this effect on serum sodium.

While some might argue that the sodium increase from a single 2 liter bolus of Normal Saline has minimal significance a hyponatremic patient’s immediate morbidity and mortality, I would argue that there are still compelling reasons to change practice. For one, as described, Ringer’s Lactate is a clearly superior crystalloid compared to Normal Saline in these circumstances. Two, we ought to be mindful of how our decisions in the ED have downstream effects. In such a complicated patient, we should attempt to optimize the conditions for success of our ICU colleagues and the patient over the ensuring hours and days of care. It is not hard to imagine the massive deliberation needed to balance the needs of multiple continuous IV infusions, volume resuscitation, and careful sodium titration in this patient. Why make it more difficult for our ICU colleagues? Finally, it is really in these critically-ill patients, where single, sometimes seemingly minor decisions, can have major impacts on their ultimate morbidity and mortality.

As an aside, for me, the most striking aspect of this trick of the trade is how it exposes the danger of using automated behaviors (a form of anchoring) irrespective of individual patient conditions. Rapid volume resuscitation is an EGDT cornerstone, which has been ingrained as gospel in medical trainees, and as strict policy at many emergency departments/ intensive care units. Additionally, use of Normal Saline as the crystalloid of first choice is largely the result of convenience and routine, rather than superiority to other crystalloid formulations. For me, this trick of the trade teaches me that I shouldn’t always use a 2 Liter bolus of Normal Saline just because it’s on my medication order “quick list.”

In summary, it is ideal to use Ringer’s lactate (or other “balanced” crystalloid solutions) as the initial choice for volume resuscitation in the undifferentiated hyponatremic, hypotensive patient, until more definitive diagnosis and disease-centric treatments can be initiated.

Derrick Lung, MD MPH
Assistant Clinical Professor, Department of Emergency Medicine, UCSF-San Francisco General Hospital; Assistant Medical Director, California Poison Control System – San Francisco Division

Expert Peer Review

Dr. Li,

Thank you for writing up this pearl. Both of the reviewers bring up great points.

1. I agree with Dr. Zuckerman’s point #4 as I am unable to find an outcome specific study in fluid resus between the usual standard care (NS 20-30 ml/kg bolus vs LR) with patient-specific safety outcomes. Based on the math, it theoretically should be a safer choice for a carefully selected cohort of patients. Please consider stating “may be the safest choice,” rather than “[it] is the safest choice.”
2. The second small change is to be consistent with your units. (cc/kg –>ml/kg).
3. From an emergency department perspective, differentiating acute vs chronic hyponatremia can be very challenging. Perhaps majority of our patients will have chronic hyponatremia, and in cases where the onset period is unknown (and there are no life-threatening symptoms), it may be best to assume chronic hyponatremia, rather than treat aggressively with NS or higher osmolality fluids. Regardless of the strategy, it would be wise to recommend close and frequent monitoring of Na (every 2 to 4 hours), starting in the emergency department while these patients continue to wait for a bed. Repeat Na can be easily overlooked during a busy shift.

Thank you again for this great pearl!

Zlatan Coralic, PharmD
Assistant Clinical Professor of Pharmacy & EM; Emergency Department Clinical Pharmacist; University of California, San Francisco

(c) Can Stock PPhoto

Venipuncture is the most common invasive procedure performed in the emergency department [1], likely due to the fact that the vast majority of our laboratory evaluations require blood and many of our life saving interventions require access to the patient’s systemic circulation. Most of the time emergency department staff are able to perform this procedure easily, but occasionally you find that your patient is the dreaded “difficult stick”. Literature suggests that the landmark technique is successful on the initial venipuncture 74-77% of the time [2][3][4][5]. Success rates rise after multiple attempts, but what happens when you don’t have the luxury of time? What happens when your patient will die if you don’t get life saving medications into their circulation promptly?  There are a few options when you can’t get IV access through traditional means, among them external jugular vein cannulation, central line, ultrasound-guided IV, and the intraosseous lines (IO) [6]. However, when managing the crashing patient, a wise decision is to use the quickest option, which is often the IO.

There are already multiple methods for confirming IO placement, including return of bone marrow, visualization of blood in the stylet, firm placement of the needle in the bone, and the ability to smoothly deliver a fluid flush [1][7]. Here, we suggest another method.

Trick of the Trade for Confirmation of IO Placement

Check for IO flush resistance while squeezing around the site of placement

Recently, I placed an IO in a crashing obese patient and afterwards noted marrow and blood return and firm placement. After flushing and beginning to bolus fluids, I noticed that this awake patient seemed to be fairly comfortable with the fluids going into his tibia. This concerned me, as I recalled that a bolus infusion into the marrow has been reported to be a painful procedure. I elected to manually compress the area around the IO with both hands, and found that flow that I thought was going into the bone halted.  This confirmed my suspicion that I had in fact likely gone through the bone, and was infusing IV fluids into soft tissue.

After the misplaced IO was removed and another was placed successfully on the contralateral tibia, the patient was successfully resuscitated and was able to be safely transported to a higher level of care. Afterwards, we did a literature search and found that we were not alone in considering this a method of IO confirmation.

Lee et al performed an experiment in the limbs of pigs and found that when the IO tip was placed in the subcutaneous tissue and the area around the needle was manually compressed, the pressure was transmitted into the syringe attached to the IO [6].

It is reasonable to assume this animal data can be applied to humans.  We’re not suggesting that this method replace other methods, but rather, that one can use this method as another tool in their quiver to help manage a crashing patient.

References