Tag Archives | Clinical Tips

Everything you could possibly want or need to know about shoulder dislocation.

It had to happen at some point.  So many reduction techniques, so many eponymous names, which ones work, which ones don’t, what’s the evidence for this technique vs that technique, my old boss showed me  this neat trick, works every time… Nitrous vs midaz vs Propfol vs accupuncture vs hypnosis, do you use a towel, a sheet or a foot in the axilla? Do you need to learn scapular manipulation or Orthopaedic Registrar manipulation?

Well now you can forget everything you’ve ever heard about shoulder dislocation and start from scratch. Check out shoulderdislocation.net, the best, most comprehensive, beatifully laid out site on shoulder dislocation you’ve ever seen. 13 videos and loads of articles on different reduction techniques, aftercare advice and more. For those just starting to learn about reducing shoulders, it will be invaluable, but there’s plenty there for the experts amongst us as well.

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Practical Tip: Fascia Iliaca Compartment Block

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Practical Tip: Paediatric IV transillumination

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Tracheostomy Complications

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High-Flow apnoeic oxygenation

I know I keep harping on about this, but these techniques may save you from a catastophe if you’re intubating someone in the ED.

The guys over at Emergency Medicine Updates have done a sweet article on the concept of nasal oxygen during RSI, but have taken it up a notch by using high-flow nasal O2.

I’m a recent convert to high-flow nasal oxygen, if you’re not sure about whether you’ve got it at your institution, ask your ICU/HDU, as they usually stock it and can send it down to ED if you need it.

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Face Mask Capnography for Procedural Sedation – tip from John Larkin

Here’s another method of monitoring EtCO2 during procedural sedation from John Larkin, an Advanced Trainee from Joondalup in WA.  It’s another way of attaching a “main-stream” EtCO2 sensor to a face mask.  Here’s how John does it:

“We used the mainstream monitor connected to a cut paediatric ETT, we used a size 3, which with a bit of mask hole dilating fits nicely. This worked really well, on a side note a can confirm that a 16G – 20G cannula works nicely for sidestream monitoring via mask”.

Here’s the pictures of John’s setup:

IMAG0153

IMAG0154

Also, a quick safety note/disclaimer. While the methods we’ve described for monitoring EtCO2 seem logical and intuitive, remember these methods have not been formally tested/studied, nor had their safety formally assessed.  There are a number of reasons these systems may not work or give accurate EtCO2 readings:
– Disconnection of any of the improvised connectors
– Blockage of any of the tubing by condensation or kinking
– Disruption of the CO2 flow to the sensor by the oxygen flowing through the mask
So by all means try them out, but please utilise all of your other standard monitors, and apply the same principles of anaesthetic safety that you’d normally use.

Please feel free to send in any other improvised ED devices that you’ve encountered, and we’ll post them!

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Send them to the gallows! Paediatric femur fracture.

A disturbing case I saw recently of a 6 month old baby who’s toddler brother was jumping on the bed and landed across the baby’s leg – snapping the femur clean in half.
paed_femur
Disturbing on many levels, including the obvious “is that really how it happened” question that I felt obliged to ask, but deferred due to the level of parental distress; disturbing as I could easily see my 2.5yr old daughter doing the same thing to my 10 month old son, (how would I explain that, I wondered…) and my inability to think of adequate analgesic options quickly (we ended up with IV fentanyl, after consulting the anaesthetist, and after I failed the IV twice and the serendipitous Paeds Reg walking by helped me get IV access), and disturbing because I assumed the baby would go straight to theatre, wrongly explained this to the parents, and then was educated by the Ortho team that they actually manage these in traction – in a device disturbingly called “gallows traction”.
gallows
Thankfully a rare enough injury, but thought I’d share the management tip in case you ever see one, as the management is non-operative in younger patients, (traction if displaced, spica if undisplaced), operative in older kids.

Here’s a nice summary over at Wheeless Online.

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Face Mask Capnography for procedural sedation – tip thanks to Minh Le Cong

Here’s a great tip for utilising standard EtCO2 monitoring equipment during procedural sedation, thanks to Minh Le Cong (@rfdsdoc)

Why is this important or useful? Because apnoea (as evidenced by loss of EtCO2 trace) is when you lose your protective airway reflexes during procedural sedation (which is when your aspiration risk starts going up), and in a patient with supplemental oxygen applied can give you advanced warning that the patient is about to start desaturating, so you can take remedial action (eg: cease the administration of sedative, apply some stimuli to get the patient to take a breath, and possibly use a reversal agent if needed).  It’s also useful to help pickup complications such as laryngospasm, particularly – as Minh points out below – in noisy retrieval vehicles.

Here’s some extra info from Minh on the technique:
We tested the setup using increasing oxygen flow rates through the hudson mask. We only found appreciable waveform degradation above 10L/min . The EtCO2 reading is of course not reliable but it still gives you a trend. The main use I find having the capnography for is in the noisy aircraft, its hard to hear someone going into laryngospasm and they can look like their chest wall is rising up and down but actually be moving no air. Sooner you realise there is a problem you can intervene before hypoxia sets in.

This is a great technique that we’d strongly encourage anyone doing procedural sedation without capnography to start using.

Another improvised capnography setup – if you have sidestream capnography – involves the use of:
1) A mixing cannula (the plastic cannula the nurses use to draw up liquid medication)
mixing_cannula

AND

2) An oxygen mask with the small exhalation holes on the side
Oxygen-Mask

and

3) Sidestream capnograph tubing.
capnograph_tubing

Basically you pull the green connector (the “syringe end”) off the mixing cannula, they come off quite easily:
mixing_cannula_tip

And plug the small end into one of the small holes on the side of the oxygen mask:
mask_cannula

and then just connect the the EtCO2 tubing to the green connector! Easy.

Needs to be closely watched for dislodgment, and remember, another reason for loss of CO2 trace is blockage of the tubing by condensation, or kinking of the tube.

Surprisingly use of EtCO2 monitoring is not routinely receommended by either ACEM (no policy/guideline on procedural sedation) or ANZCA, merely that there should be “access to it”.  Personally I’ll be using it from now on!

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How to manage a surge in your ED

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Public Service Announcement: Splinting & Cellulitis

After seeing mutliple cases of upper & lower limb cellulitis that had “failed” oral antibiotics last week, some referred from GP’s, and some who had treatment started in my ED, I have to vent… (Sorry for those Registrars at RDH that have had to listen to me go on about this already). This may not come up in your exam, but it is one of the most poorly done aspects of ED patient referral/management that I see, and it does my head in.

If you diagnose someone with cellulits in the upper limb, who is otherwise well and suitable for outpatient antibiotic treatment, you MUST immobilise the limb.  For infections above the elbow that means a sling, for forearm and hand infections that means a volar POP slab down to the fingertips and a sling.  For lower limb infections in a compliant adult patient, you may get away with just using crutches. For everyone else, a POP backslab is necessary. Don’t use circumferential padding, just make a padded slab, and wrap it on with a crepe bandage.

The commonest reason I see people “fail” oral antibiotics is that they are not adequately immobilised.  Your hands are constantly moving, even with your arm in a sling, your fingers will move, a lot.  This pumps your lymphatics, expands & contracts your soft tissues, and makes soft tissue infections spread.  Walking on a celulitic lower limb does the same thing. Ever referred a nasty limb infection to a plastic surgeon? What do they ask you to do? “Put a slab on please”. People that get admitted get splints/slabs, why don’t outpatients?

I can’t find any published literature on this, (although here’s a chapter from “Practical Plastic Surgery for Nonsurgeons” that backs me up) but at the risk of using dogma/common sense over science, please don’t send anyone home from your ED with limb cellulits without immobilising them. And if you know anyone who is a GP in Australia, please send them a link to this article.  For the GP’s, please don’t refer anyone to ED with “failed oral antibiotics, needs IV” for limb cellulitis if they haven’t had at least 48hours of oral antis and proper immobilisation, unless they have other signs like a fever or systemic symptoms that would mandate IV antis.

And on that note, DON’T USE FIBREGLASS to make your splints/slabs.  Use plaster. Especially in kids, the elderly, diabetics, the congnitively impaired, the immunocompromised, and those with sensory impairment (neuropathy/post nerve block). This article outlines some of the scary complications that can result from those little scracthes you get from fibreglass slabs. One kid had his arm amputated.

Alright, that’s my rant on splinting and cellulitis.  Now get back to your exam study!

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