1. Care for hand injuries more efficiently, including administering anesthesia and applying tourniquets to individual fingers.

2. Use the hip auscultation test to determine whether patient should have magnetic resonance imaging.

3. Insert a femoral line in a pulseless patient.

4. Describe the metabolic consequences of therapeutic hypothermia.

5. List the indications for therapeutic hypothermia.

Tricks of the Trade
Michelle Lin, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of California, San Francisco, School of Medicine, and Associate Program Director, UCSF-San Francisco General Hospital Emergency Medicine Residency

Case 1: 30-yr-old pedestrian struck by automobile; suffers multiple injuries and abrasions, including gravel embedded in right palm, laceration of right index finger with persistent oozing, fractures of right second metacarpal and left distal radius

Anesthetizing right palm to remove gravel: administer regional anesthesia at median nerve in wrist, between palmaris longus, flexi carpi radialis; for radial nerve, start superficially at radial styloid and “just put a huge wheal through the entire dorsum of the wrist”; if ultrasonography (US) available, perform forearm US-guided nerve (FUN) block (inject at forearm level rather than wrist); nerves appear bright white (hyperechoic); advantages— FUN block reduces risk for compartment syndrome; medication far from injured area; landmarks not obscured

Stopping oozing of right index finger: apply glove-ring tourniquet; vasculature for each finger supplied by radial and ulnar digital arteries; external compression creates hemostasis; snip little finger off glove, snip hole in tip, slip onto your finger and roll back to create ring, then place on patient’s finger; avoids hemostasis of entire hand; bandaging laceration—use band netting (tubular, cloth-like, elastic material that fits over finger like sock); if finger applicator unavailable, load onto pelvic speculum and put on patient’s finger; apply 3 to 4 layers, leaving “tail”; snip longitudinally to create second tail, then tie together at wrist; do not use if patient has digital neuropathy (ascertain that patient has finger sensation first)

Second metacarpal fracture: immobilize one joint distal and proximal to injury; volar wrist splint immobilizes everything except thumb (may be excessive for this injury); radial gutter splint—similar to ulnar gutter splint; bisect 4-in fiberglass (Ortho-Glass) longitudinally from fingertip to patient’s wrist; sandwich around second and third metacarpal; leaves fourth and fifth digits free while stabilizing second and third metacarpals on dorsal aspect, which is more stable than immobilizing volar aspect alone

Left distal radius fracture: immobilize wrist, elbow from flexing, pronating, and supinating; sugar-tong forearm splint used traditionally, but difficult to fit on elbow; apply reverse sugar-tong splint (put bend [“U”] of sugar- tong at wrist (palm), with tails falling toward elbow; cut 4-in orthoglass almost in half, leaving small amount of padding resting in first web space; tails then can tuck in snugly along elbow and fit more securely; wrap as usual; take-home message—consider reverse sugar-tong splint if conventional splinting leads to too much buckling at elbow

Case 2: 80-yr-old man complains of right hip pain after falling down stairs; leg bears minimal weight; plain films normal in up to 9% of femoral neck fractures; must decide whether to perform magnetic resonance imaging (MRI; computed tomography [CT] also acceptable); no external rotation present to suggest large break; risk stratification—hip auscultation test; uses fact that bone conducts sound very well; apply stethoscope to symphysis pubis; percuss each patella; volume discrepancy suggests fracture in bone with lower volume; in one study, positive predictive value was 98% after excluding patients with characteristics that increase possibility of false positive findings (eg, severe osteoarthritis of hip or knee; hardware in extremity of interest); positive test indicates need for MRI or CT

Case 3: female patient, highly agitated; cannot remain still; pupils dilated; has tachycardia (140 bpm); history of cocaine and intravenous heroin use; appears to be bleeding from scalp; challenge to calm patient sufficiently to perform head CT

HAC regimen: intramuscular (IM) sedation using 5 mg haloperidol (Haldol), 2 mg lorazepam (Ativan), 1 mg benztropine (Cogentin), all in 1 syringe; however, IM absorption of haloperidol and lorazepam irregular (wide variation in patient response); midazolam (Versed) most consistently absorbed IM benzodiazepine known; “super short-acting”; 5-mg injection works faster, more consistently, and wears off more quickly than haloperidol or lorazepam administered individually; administered to this patient, who then underwent head CT

After CT: patient complains of subacute back pain, has tenderness over length of spine; after examination, patient curls up in fetal position and refuses to answer any more questions; must rule out spinal epidural abscess; risk stratification—red flags suggesting high likelihood of abscess include fever, back pain, history of IV drug abuse; Waddell’s signs provide “green flags” suggesting low likelihood of abscess

Waddell’s signs: help differentiate between organic and nonorganic causes of back pain; axial scalp loading— should not cause pain; “if they complain of back pain, that doesn’t make sense”; distracted straight-leg raise— clinician passively elevates patient’s leg to flex hip; if sciatica present, pain shoots down leg past knee (with back pain); next, have patient extend knee while seated; if no back pain occurs, sign negative; simulated rotation—“log roll” patient so spine remains aligned with shoulders and pelvis; should not cause back pain

Hoover test: perform during straight-leg raise; tests strength of muscles involved in hip flexion; clinician cradles patient’s heel as patient tries to lift opposite leg; should feel compensatory pressure in heel as patient tries to lift leg; if pressure absent, suggests patient not really trying to lift leg

Spinal percussion tenderness: percussion of individual spinous processes; irritates spinal pathologies such as deep epidural abscesses; true red flag

Case 4: 50-yr-old man presents with eye pain after being pepper-sprayed by police during altercation; perform visual acuity and slit-lamp examinations; insert Morgan lenses and irrigate eyes; patient’s eyes extremely sensitive; have him close eye, then apply 3 to 4 drops anesthetic in natural “well” in medial canthus; as eyelid opens gradually, medication drips into eye

Alternative method of eye irrigation: attach IV tube to nasal cannula; rest cannula over nasal bridge so each eye irrigated; place towels around patient’s head to absorb runoff; occasional addition of more anesthetic

Visualizing orbit when eyelids swollen shut: if eyelid retractors not available, bend paper clip to 90o , use that to pry lid open; pearl—examine traumatized eye as soon as possible, since lids continue to swell

Case 5: 80-yr-old woman in pulseless electrical activity (PEA) arrest; nurses cannot establish peripheral line, so prepare her for femoral line; must rely on external landmarks to find femoral vein; 23% failure rate of finding femoral vein in pulseless patients; V technique—place thumb on pubic tubercle, index finger on anterior superior iliac spine (ASIS); femoral vein lies under first web space; insert line and stabilize patient

Inserting subclavian line: 10% risk that it will go up ipsilateral internal jugular (IJ) instead; finger-in-fossa technique— have assistant place finger in supraclavicular fossa, occluding IJ, then feed guide wire through subclavian vein; eliminates risk of wire going into IJ; patient complaints of ear pain, tickling in throat suggest wire in IJ

Case 6: 25-yr-old woman sustains clean, shallow laceration near upper eye lid; lacerations near eye relative contraindication for tissue adhesives

Techniques for safe wound closure using adhesive: for wounds above eye level, place patient in Trendelenburg’s position, so adhesive runs superiorly toward hair; cover eyelashes and eye lid with petroleum jelly (impermeable to tissue adhesive); fold piece of transparent chlorhexidine dressing (Tegaderm) in half, cut out circle size of adhesive aliquot, apply adhesive to this, then apply dressing to wound

Case 7: 23-yr-old man presents with sore throat, right-sided peritonsillar swelling, and uvular deviation; can use intracavitary probe for US of peritonsillar space; abscesses appear as encapsulated structures with hypoechoic (dark) pus or fluid

Needle aspiration of peritonsillar abscess: curved laryngoscope blade provides tongue blade and light source and requires only one hand; anesthetize oropharynx to reduce gag reflex; use spinal needle for aspiration; trim sheath to desired depth to guard against going too deep

Case 8: 40-yr-old homeless man arrives by ambulance; has humeral abscess 10 cm in diameter; severe foot odor; “toxic sock syndrome”—perspiration and bacteria accumulate in socks in humid environment and produce foul- smelling isovaleric acid; neutralize with bicarbonate or over-the-counter antacid (eg, Mylanta, Maalox); “antacid booties”—put 30-40 mL antacid into booties, put on patient’s feet; neutralizes odor within 1 to 2 min; minimize purulent smell from abscess drainage by suctioning pus into canister (take pus from one closed system to another); after most of pus drained, extend incision and look for loculations

Therapeutic Hypothermia
Scott Rodi, MD, MPH, Assistant Professor of Medicine, and Assistant Director, Section of Emergency Medicine, Dartmouth- Hitchcock Medical Center, Lebanon, NH

Therapeutic hypothermia: defined as 32o to 34o C core temperature; temperature at which hypothermic side effects occur (eg, shivering, altered mental status, risk for cardiac dysrhythmias, impaired immune function, coagulopathies)

Physiologic role: neuroprotection; slows or prevents neuronal cell death; metabolic rate slows, imposing less metabolic demand; for every degree core temperature drops, metabolic demand decreases by 5% to 7%; also associated with decreased intracranial pressure, interruption of excitotoxic cascade (release of cytokines, inflammatory mediators and O2 radicals), better maintenance of blood-brain barrier, improved membrane stability, decreased protease formation, less glutamate toxicity, reduced calcium influx; slows rate at which cells die, giving clinicians more time to treat patient using agents that act slowly or cannot be introduced immediately after injury

Therapeutic applications: shown beneficial inly after cardiac arrest; other possibilities include traumatic brain injury (TBI), stroke, and neonatal encephalopathy; classic indication is persistent coma following return of spontaneous circulation

Post-cardiac arrest: 2 studies published in 2002; in both, patients sustained witnessed cardiac arrest, brief time to arrival of emergency medical services, initial ventricular fibrillation or tachycardia; spontaneous return of circulation, stable vital signs upon arrival; in first study—hypothermia induced in field, maintained for 12 hr, followed by spontaneous warming; patients who did not undergo hypothermia received more cardiopulmonary resuscitation (CPR); 49% of hypothermia group had good outcome, compared to 26% of CPR group (statistically significant); number needed to treat (NNT) for one good outcome, 4; in second study—hypothermia maintained for 24 hr using cooling blanket; 55% of those patients had favorable neurologic outcome, compared to 39% of normothermic patients; mortality 41% among hypothermic patients, 55% among normothermic patients (both findings statistically significant; NNT 6 to prevent poor neurologic outcome; NNT 7 to prevent 1 death); however, hypothermia associated with high risk for pneumonia

2005 Statement by International Liaison Committee on Resuscitation (ILCOR): recommended 12 to 24 hr of hypothermia for unconscious, post-cardiac arrest patients with spontaneous circulation if official rhythm ventricular fibrillation; noted that cooling may also be beneficial for other rhythms and for in-hospital cardiac arrest; considered standard of care for appropriate patients

Use in TBI: no definite benefit shown yet

Use in stroke: may help limit damage to tissue around infarcted area (penumbra); when inducing hypothermia, patients usually sedated, intubated, and paralyzed; may require change of practice for stroke victims

Use in neonatal encephalopathy: 2005 study showed hypothermia of benefit in subgroup of infants with relatively mild damage as shown on electroencephalography

Other areas of potential benefit: hepatic encephalopathy, meningitis, spinal cord injury, post-myocardial infarction, acute respiratory distress syndrome, subarachnoid hemorrhage, fever (often used to control fever associated with postoperative sepsis)

Techniques: infusion of cold saline; application of ice bags; use of cooling blanket; packing patient in ice; commercial devices (helmets to cool brain; ThermoSuit; intravascular cooling devices); cold saline (study)—effective and inexpensive; also associated with improved mean arterial pressure, renal function, with no increased risk for pulmonary edema; studies of endovascular device—showed hypothermia beneficial to patients with asystole, PEA, as well as ventricular fibrillation and ventricular tachycardia; showed hypothermia may also be useful for stroke patients; device used to cool core while periphery kept warm (reduced shivering and discomfort)

Complications: cooling patient excessively; dysrhythmias; pneumonia; principal complications—decreased cardiac output from dysrhythmia; impaired coagulation; impaired immune function, resulting in increased risk for infection); slowing of drug metabolism (consider decreasing drug dosages); cold-induced diuresis, leading to volume shifts as patient is cooled, then rewarmed; electrolyte shifts; decreased insulin secretion resulting in tendency toward hyperglycemia; shivering; difficulty in interpreting blood gas data; pearls—meticulous intensive care unit care required; rewarm patient slowly to decrease risk for excessive volume shifts and increased intracranial pressure