EMERGENCY TIPS AND TRICKS
| EMERGENCY DEPARTMENT TIPS AND TRICKS —Loren Crown MD, Clinical Professor of Family Medicine and Emergency Medicine, University of Tennessee Health Sciences Center, Memphis, and Emergency Medicine Fellowship Director, Baptist Memorial Hospital-Tipton, Covington, TN |
| Medical treatment tips and tricks: for pain of sore throat—popsicles; solution of half calcium carbonate antacid (eg, Maalox) and half diphenhydramine (Benadryl); viscous lidocaine 50/50 with any antacid; hot pack consisting of microwaved clean wet diaper; cold pack consisting of bag of frozen peas; corneal abrasions—patches no longer used (lack efficacy and create wet dark hypoxic environment that breeds germs); renal colic—cannot flood stone out with intravenous (IV) solution; meperidine (Demerol) used for short-term pain relief; morphine also used; ketorolac (Toradol) often used; urologists using α-blockers, calcium channel blockers, desmopressin (DDAVP), and steroids; intoxicated patients—increase alcohol clearance by 50% by feeding them; IV saline ineffective; hemorrhoids—most products not helpful, but those that combine anti-inflammatory agents with anesthetics do help, eg, hydrocortisone preparations (eg, Anusol-HC, ProctoFoam-HC); mesalamine (eg, Asacol) also used; insert suppositories blunt end first; anal fissures—nitroglycerin ointment superior to other agents; nasal inhalers—have patient aim for ear and look at floor; sickle cell crisis—usual treatment large amounts of IV fluids, oxygen, and pain medication; no evidence IV fluids effective unless patient dehydrated (oral fluids faster); no evidence that oxygen helpful unless patient hypoxic; pain medicine should be given IV and titrated, but since veins in these patients usually blocked, fentanyl lollipop best alternative; refractory urticaria—diphenhydramine, H2 blockers, doxepin, asthma medications eg, montelukast (Singulair); “one amp” rule—most drugs used in emergency pharmacology packaged in ampules; if unsure of dosage, give one ampule; toxicology—no evidence for routine use of ipecac, charcoal, cathartics, or lavage; give charcoal for carbamazepine (Tegretol), dapsone, phenobarbital, quinine, and theophylline; no proven benefit for whole-bowel irrigation; gastric lavage associated with morbidity, eg, injury to mucosa, reflux, aspiration; ethylene glycol causes urine to fluoresce when viewed with Wood’s lamp |
| Diagnostics: modified guaiac (Hemoccult) test—wait 3 to 5 min for sample to disperse before adding developer; deep venous thrombosis (DVT)—pump blood pressure cuff on unaffected side to point of pain, then repeat on affected side (point of pain occurs sooner; Lowenberg’s sign); theoretically, could propel clot into central circulation, but so could test for Homans’ sign and compression during ultrasonography; eye examination—use ophthalmic anesthesia in both eyes; draining knee—use plastic angiocatheter over needle; once in joint, remove needle and leave angiocatheter; this makes withdrawing fluid less painful; use vacuum system, eg, Vacutainer, to remove fluid and fill tubes; inject small bolus of air to act as marker on x-ray; to facilitate expression of fluid, compress knee by wrapping with elastic bandage (eg, Coban) leaving small window as work site; acidosis—arterial blood gases (ABGs) not needed; venous pH accurate (±0.03); computed tomography (CT) before lumbar puncture (LP)—do LP first, unless altered mental status, papilledema, or clinical indications present; x-rays — glass 99% visible; bones from saltwater fish usually visible, those from freshwater fish not visible; tabs from aluminum cans not visible; facial trauma—look for orbital or facial bone fractures by testing for sensitivity along distribution of branches of facial nerve; fractures almost always go through foramina, and if foramen cracked, patient will have hypesthesia in corresponding branch; cultures—99% of time, positive in first 24 hr; pediatric breath sounds—pinch nose to decrease adventitial sounds; teachable moment for smoker—listen to lungs, pause, and ask patient if he or she smokes; best time to talk about smoking cessation; urine sample from infant—wringing out wet diaper may provide good sample, provided it has not been left on infant too long; radiation from x-rays—not trivial; for backache, CT or MRI needed only if surgery indicated; kidney-ureter-bladder (KUB) equivalent to ≤50 chest x-rays; weighing large patients—use 2 scales, one foot on each, and add readings |
| Procedures: inserting nasogastric tube—painful for patient; use lidocaine spray or jelly in nose before insertion; cryoprocedures—use nasal speculum to focus spray; visualization of cervix—cut finger from latex gloves and place over speculum blades to keep side wall of vagina from collapsing into visual field; or use one speculum horizontally, one vertically; fibromyalgia attacks—trigger point injections, fanned out, with multiple punctures; Foley catheter that does not deflate—instill cola into catheter bladder to disintegrate latex; do not hyperinflate and explode balloon; epistaxis—patient with posterior pack or both sides packed should be admitted because of possibility of desaturation, aspiration of pack, or having clot dangling from pack; hiccups—apply pressure to uvula with cotton- padded tongue blade; “toxic sock syndrome”—patient wearing same socks for extended period; saturate surgical bootie with Maalox and water and massage onto foot; wait 1 hr, remove sock; removing fish hook—24-in loop of string tied in knot around curve of hook, indent hook parallel to skin surface, and pull quickly; stuck zipper—use needle-nose pliers with cutter to cut circular part of zipper that goes from front to back half; or cut intact zippe below slider; use local anesthetic before procedure; ring removal—slide string under ring; distal to ring, wrap finger tightly with string down to next knuckle and tape in place; take proximal end of string and unwrap sequentially; works better if rubber tourniquet placed on arm, and arm elevated and chilled before procedure; speaker does digital block before procedure; ring cutters painful |
| Foreign bodies: in ears—use “crazy glue” or contact cement on cotton-tipped swab to remove object; for wax impaction, place any ear drops (speaker uses docusate [eg, Colace]) in affected ear and have child lie with that ear facing up for 10 to 15 min; then have child turn over for another 10 to 15 min so affected ear down and fluid with liquified wax drains out; in nose—use “parent’s kiss,” ie, have parent occlude open nostril and puff into child’s mouth; child instinctively closes glottis and air comes out other side with foreign body; may use phenylephrine (eg, Neo-Synephrine) drops first; eyes—use fluorescein to see object(s) and damage done; use slit lamp; after removing object, evert eyelid to be sure companion object not stuck under eyelid; ask patient if object was propelled; ticks— regurgitation and release of infectious components into patient occurs if tick squeezed or suffocated; instead, loop thread around tick at level of skin, tighten and pull; this breaks body from mouth; then scrape off mouth parts with scalpel; foreign body in finger—darken room and shine penlight through finger to reveal foreign body; may also be done with otoscope; impacted food bolus—if patient in good health, offer dilating agent (eg, glucagon), EZ gas crystals (produce carbon dioxide when wet; can cause esophageal rupture), nitroglycerin, or calcium channel blocker; paint gun and injector injuries—serious condition; refer to plastic surgeon immediately; eyelids glued together—let it wear off or use any petroleum product (eg, Vaseline, baby oil); also works for gravel and asphalt embedded in skin; rectal foreign bodies—Foley catheter threaded past smooth object; inflation of catheter may eject object; ring forceps or single-tooth tenaculum may work |
| Orthopedics: mandibular fracture—have patient bite tongue blade; if physician can shake patient’s head while patient bites tongue blade, not likely mandible broken; clavicle fracture—figure-of-8 bandage no longer used; apply sling; sacroiliac (SI) joint—press hand hard on joint or have patient stand on one leg; if patient has pain on ipsilateral side, SI joint problem confirmed; digit reduction—grab digit and have patient lean back; administer digital block first; lumbar spine fractures—nasal calcitonin and hydrocodone (eg, Lortab) reduce pain in elderly patient with osteoporosis; reflex ileus present due to fracture (also caused by narcotics); checking for fracture—tap distal bone (eg, patella) and listen proximally (eg, ischial tuberosity) with stethoscope; if tap heard proximally, bone not fractured; sound not transmitted if bone broken; knee injuries—brace makes most injuries feel better during first 3 days; apply ice, prescribe pain medicine, and follow up; sports enthusiasts—inspect wear pattern on shoes to detect pronation or supination problems; advise patient to replace shoes every 500 miles; ankle sprains—brace, or use high-top shoes to prevent inversion injuries (most common) |
| Dental problems: postextraction bleeding—tea bag (tannic acid vasoconstricts); have patient bite down hard on bag (without breaking bag) for ≈20 min; cavity—clove oil (eg, Eugenol) placed in cavity relieves pain; tooth fracture— dental wax, sugarless gum, or crazy glue on crack |
| Not covered in medical school: patients—prefer quick pain relief; start pain medication before sending patient for x- rays; do not forget to give steroids to asthmatics and aspirin to patient who has had myocardial infarction; before entering room—identify patient’s personal physician; ascertain insurance coverage (to know referral patterns); find out when patient last seen in ED; upon entering room—introduce self, make physical contact, sit down, ask patient how you can help him or her, and give patient time to talk; perform examination that counts; calling patient’s family physician—give diagnosis, patient’s stability, test results, then result of history and physical examination |
| Pain medication: narcotics not always necessary; use maximal doses of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs); up to 20% of population cannot metabolize codeine, so use hydrocodone instead; propoxyphene should not be used because of toxic metabolites and lack of efficacy; tramadol no better than placebo in most studies; ketorolac expensive, and should be used only once in ED (side effects with continuous use); NSAIDs not shown to help heal soft tissue injuries and shown to delay healing; meperidine for one-time use because analgesic effect ends before elimination of metabolites that cause side effects; start morphine dosing at 0.1 mg/kg IV, and titrate |
| Final tips: vital signs important; recheck and explain abnormals; ABGs not helpful; ask patient what worked in past (will probably work again); if physician does not know what patient has in 5 min, he or she probably will not know in 5 hr; if patient in ED 3 times with same undiagnosed complaint, admit; every patient should get something (eg, test, treatment) before leaving ED; speaker opines that patient satisfaction scores not useful |
| MEDICOLEGAL INFECTIOUS DISEASE CASE —Gregory A. Moran, MD, Clinical Professor of Medicine, and David A. Talan, MD, Professor of Medicine, Department of Emergency Medicine, Division of Infectious Diseases, the David Geffen School of Medicine at the University of California, Los Angeles, and Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, CA |
| Initial case presentation: woman 45 yr of age with complaint of fever, mouth blisters, sore throat, and rash; temperature 103°F, pulse 125 per min, blood pressure 126/70 mm Hg, O2 saturation 94%, respirations 18 per min; patient on drug therapy for anxiety; allergic to hydrocodone (Vicodin); physical examination—patient alert and anxious; mucosa dry; erythematous pharynx; enlarged lymph nodes; tonsils with exudate, no edema; conjunctivitis; no oral blisters; positive dry lips; no swelling; no skin rash; remainder of examination unremarkable; laboratory values— white blood cell count 5000/µL, 75% segmented neutrophils, 16% lymphocytes; treatment—ketorolac, 2 L normal saline; on re-examination at 4 hr, vital signs normal and temperature decreased; patient feeling better; summary of findings—patient with sore throat, bilateral conjunctivitis, rhinorrhea, fever, body aches, mild cough, and no rash (although patient insists rash exists); diagnosis—viral syndrome with mild dehydration; patient argued for antibiotics (azithromycin prescribed at patient’s insistence); discharge instructions—see personal physician in morning; patient does not need antibiotics; risks of antibiotics explained; return to ED for worsening symptoms or any other concerns |
| Later course: 5 days later, patient found confused and febrile with skin peeling off; brought to ED, then transferred to burn center because 90% of skin sloughing off; corneal damage; patient intubated; multiple debridements necessary; eye surgery performed; patient in hospital 1 mo, then months more in rehabilitation facility; now has impaired vision and chronic pain; diagnosis—Stevens-Johnson syndrome |
| Stevens-Johnson syndrome: before rash, often presents like upper respiratory infection |
| New information: 2 wk before ED visit, patient treated with phenobarbital and carbamazepine while in rehabilitation for drug and alcohol abuse; phenobarbital and carbamazepine, but not azithromycin, associated with Stevens- Johnson syndrome; patient sues ED physician for not diagnosing Stevens-Johnson syndrome and for not admitting patient |
| Legal issues: plaintiff’s expert—misdiagnosis as viral syndrome; failure to diagnose Stevens-Johnson syndrome; failure to admit to hospital; prescribing azithromycin; failure to obtain complete history (patient claims she told physician about drugs taken during rehabilitation); even though patient demanded antibiotic, physician should not have prescribed it; defense—patient had not revealed she had been in drug rehabilitation 2 wk before (where she was treated with carbamazepine and phenobarbital); no good treatment for Stevens-Johnson syndrome other than supportive care; case settled in favor of defense |
Suggested Reading
Abd-el-Maeboud KH et al: Rectal supppositories: Commonsense and mode of insertion. Lancet 338:798, 1991; Bond GR: Home syrup of ipecac use does not reduce emergency department use or improve outcome. Pediatrics 112:1061, 2003; Bond GR: The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of- the-art review. Ann Emerg Med 39:273, 2002; Eddleston M et al: Does gastric lavage really push poisons beyond the pylorus? A systematic review of the evidence. Ann Emerg Med 42:359, 2003; Eidelman A et al: Topical anesthetics for dermal instrumentation: a systematic review of randomized, controlled trials. Ann Emerg Med 46:343, 2005; Lewis C et al: Dental complaints in emergency departments: a national perspective. Ann Emerg Med 42:93, 2003; Marshburn TH et al: Goal-directed ultrasound in the detection of long-bone fractures. J Trauma 57:329, 2004; Middleton DB: Thrombophlebitis. Emergency Med 10:6, 2004; Moore MN: Orthopedic pitfalls in emergency medicine. South Med J 81:371, 1988; Position paper: Ipecac syrup: J Toxicol Clin Toxicol 42:133, 2004; Rupp T et al: Inadequate analgesia in emergency medicine. Ann Emerg Med 43:494, 2004; Sanders DY et al: Sickle cell vaso-occlusive pain crisis in adults: alternative strategies for management in the emergency department. South Med J 85:808, 1992; Weaver CS et al: Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med 41:134, 2003; Yale SH et al: Approach to the vaso-occlusive crisis in adults with sickle cell disease. Am Fam Physician 61:1349, 2000.
Educational Objectives
| The goal of this program is to improve the management of common conditions seen in the emergency department (ED). After hearing and assimilating this program, the clinician will be better able to: |
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1. Use simple, yet effective methods for managing common conditions, eg, sore throat, renal colic, sickle cell crisis, drug overdose. |
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2. Diagnose deep venous thrombosis and facial nerve injury, as well as obtain a urine sample from an infant and weigh large patients. |
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3. Insert a nasogastric tube, visualize the cervix, deflate the bulb of a Foley catheter, and remove foreign bodies from the ears, eyes, and nose. |
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4. Check for fractures of the mandible and long bones, and relieve the pain of fractures of the lumbar spine. |
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5. Adopt a demeanor that is both effective and respectful for making first contact with a patient in the ED and for contacting the patient’s personal physician. |
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed: Dr. Moran has received research grants from Pfizer, Johnson and Johnson, and Wyeth. He has also been a speaker for Pfizer, Cubist, and Schering-Plough. Dr. Talan has been on advisory boards for Pfizer, Ortho-McNeil, Astellas, and Schering-Plough. Dr. Crown reports nothing to disclose.
Acknowledgements
Dr. Crown spoke in Hot Springs, AR, at the Symposium on Critical Care and Emergency Medicine, presented March 29-31, 2007, sponsored by the University of Arkansas for Medical Sciences College of Medicine and University of Tennessee Health Sciences Center College of Medicine. Drs. Moran and Talan spoke in Las Vegas, NV, at the 20th Annual Advances in Emergency Medicine and Primary Care, presented April 18-20, 2007, and sponsored by Olive View-UCLA Medical Center, Department of Emergency Medicine, and the American College of Emergency Physicians, State Chapter of California, Inc. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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